Drug-induced Hypoglycemia Research Articles

Conceptual framework and responding approach of treatment burden of type 2 diabetes mellitus: A video recording-based qualitative analysis

BackgroundPatients with type 2 diabetes mellitus (T2DM) frequently face a considerable treatment burden. Research on the specific treatment burden associated with T2DM is still in its early stages both in China and worldwide. ObjectiveBased on video recordings of clinical diagnostic and therapeutic scenarios, this study aims to summarize the conceptual framework of treatment burden related to T2DM among patients in China Mainland and explore proactive coping strategies of general practitioners (GPs). MethodsThe researchers conducted a retrospective qualitative analysis using video records that filmed during 2018-2019 from general practice training clinics of a standardized training base in Guangdong Province of China. This analysis was integrated with the existing conceptual framework of treatment burden, employing qualitative research methods such as observational record forms, field notes, coding extraction and thematic analysis. ResultsFrom 25 video records, 49 instances of doctor-patient communication related to the treatment burden of T2DM were selected and analyzed. All six themes from the original conceptual framework were explored. Additionally, the researchers identified two additional thematic items (medical information burden and drug-induced hypoglycemia). The finding led to the development of a modified conceptual framework for the treatment burden of T2DM, encompassing seven observable dimensions: financial burden, medication burden, medical management burden, lifestyle change burden, healthcare system burden, time/travel burden, and medical information burden. Each sub-theme's definition was expanded accordingly. The consultation process analysis indicated that trained GPs can actively respond to treatment burdens (medication burden, medical information burden, time/travel burden, lifestyle change burden) using skills such as patient education, enhanced communication, shared decision-making and motivational interviewing. ConclusionThe study constructs a modified conceptual framework for the treatment burden of T2DM. By integrating the identification of conceptual dimensions in clinical diagnosis and treatment, it explores how Chinese GPs can use doctor-patient communication skills to proactively address specific treatment burdens of T2DM patients.

Drug-Induced Hypoglycemia in Neonates Born to Nondiabetic Women Treated with Medications during the Pregnancy or the Labor: A Systematic Review of the Literature.

The prompt identification of at-risk newborns for drug-induced hypoglycemia can minimize the risk for adverse side effects, inappropriate investigations, and considerable unnecessary costs. Existing literature discusses drug-induced hypoglycemia, but a systematic description of neonatal hypoglycemia induced or exacerbated by maternal medications is missing. We reviewed the association between neonatal hypoglycemia and maternal medications. We systematically searched the literature according to the PICOS model on drug-induced hypoglycemia in neonates born to nondiabetic women treated with medications during the pregnancy or the labor. The main outcomes of the review were: (1) prevalence of hypoglycemia, (2) risk factors and potential confounders, (3) time at onset and severity of hypoglycemia, (4) dose-response gradient, (5) metabolic features of hypoglycemia, (6) modalities to treat hypoglycemia, and (7) quality of the studies. We included 69 studies in this review and we identified 11 groups of maternal drugs related to neonatal hypoglycemia. Results were classified for each outcome. Our review aims at supporting clinicians in the identification of the newborn at risk for hypoglycemia and in the differential diagnosis of neonatal hypoglycemia. Further studies are necessary to assess the risk of neonatal hypoglycemia associated with common maternal medications. KEY POINTS: · A systematic description of neonatal hypoglycemia induced or exacerbated by maternal medications is missing.. · In our review we identified 11 groups of maternal drugs related to neonatal hypoglycemia.. · Our review aims at supporting clinicians in the identification of the newborn at risk for hypoglycemia..

Drug-induced hyperinsulinemic hypoglycemia: An update on pathophysiology and treatment.

The initial step for the differential diagnosis of hypoglycemia is to determine whether it is hyperinsulinemic or non hyperinsulinemic. Existing literature discusses drug-related hypoglycemia, but it misses a focus on drug-induced hyperinsulinemic hypoglycemia (DHH). Here we reviewed the association existing between drugs and hyperinsulinemic hypoglycemia.We primarily selected on the main electronic databases (MEDLINE, EMBASE, Web of Science, and SCOPUS) the reviews on drug-induced hypoglycemia. Among the drugs listed in the reviews, we selected the ones linked to an increase in insulin secretion. For the drugs missing a clear association with insulin secretion, we investigated the putative mechanism underlying hypoglycemia referring to the original papers.Our review provides a list of the most common agents associated with hyperinsulinemic hypoglycemia (HH), in order to facilitate both the recognition and the prevention of DHH. We also collected data about the responsiveness of DHH to diazoxide or octreotide.

The Drug-Induced Hypoglycemia in Children: Is Levetiracetam Incriminated?

Levetiracetam is a well-tolerated anticonvulsant drug, but associated with some adverse effects. To date, there is no report of hypoglycemia associated with levetiracetam. We report the case of a 6-year-old female patient who developed symptomatic hypoglycemia after initiation of treatment with levetiracetam for her refractory status epilepticus and we review the literature to identify other reports of hypoglycemia. Associated with levetiracetam in children in order to highlight this rare adverse effect and a possible dose effect. Hypoglycemia is a rare and underestimated adverse effect of Levetiracetam and which must be taken into account and treated appropriately, in particular when high doses are given; allowing a saving of a multiple of unnecessary additional examinations.

The Impact of Hypoglycemia on Productivity Loss and Utility in Patients With Type 2 Diabetes Treated With Insulin in Real-world Canadian Practice: Protocol for a Prospective Study.

BackgroundType 2 diabetes mellitus (T2DM) imposes a substantial burden owing to its increasing prevalence and life-threatening complications. In patients who do not achieve glycemic targets with oral antidiabetic drugs, the initiation of insulin is recommended. However, a serious concern regarding insulin is drug-induced hypoglycemia. Hypoglycemia is known to affect quality of life and the use of health care resources. However, health economics and outcomes research (HEOR) data for economic modelling are limited, particularly regarding utility values and productivity losses.ObjectiveThis real-world prospective study aims to assess the impact of hypoglycemia on productivity and utility in insulin-treated adults with T2DM from Ontario and Quebec, Canada.MethodsThis noninterventional, multicenter, 3-month prospective study will recruit patients from 4 medical clinics and 2 endocrinology or diabetes clinics. Patients will be identified using appointment lists and enrolled through consecutive sampling during routinely scheduled consultations. To be eligible, patients must be aged ≥18 years, diagnosed with T2DM, and treated with insulin. Utility and productivity will be measured using the EQ-5D-5L questionnaire and Institute for Medical Technology Assessment Productivity Cost Questionnaire, respectively. Questionnaires will be completed 4, 8, and 12 weeks after recruitment. Generalized estimating equation models will be used to investigate productivity losses and utility decrements associated with incident hypoglycemic events while controlling for individual patient characteristics. A total of 500 patients will be enrolled to ensure the precision of HEOR estimates.ResultsThis study is designed to fill a gap in the Canadian evidence on the impact of hypoglycemia on HEOR outcomes. More specifically, it will generate productivity and utility inputs for the economic modeling of T2DM.ConclusionsInsulin therapy is expensive, and hypoglycemia is a significant component of economic evaluation. Robust HEOR data may help health technology assessment agencies in future reimbursement decision-making.International Registered Report Identifier (IRRID)PRR1-10.2196/35461

Alcohol exacerbated biochemical and biophysical alterations in liver mitochondrial membrane of diabetic male wistar rats – A possible amelioration by green tea

Alcohol exacerbated biochemical and biophysical alterations in liver mitochondrial membrane of diabetic male wistar rats – A possible amelioration by green tea

68 Ga-DOTATATE PET/CT imaging in endogenous hyperinsulinemic hypoglycemia: A tertiary endocrine centre experience.

Literature regarding utility of 68 Ga-DOTATATE PET/CT in insulinoma localization across various subgroups [benign/malignant/multiple endocrine neoplasia-1 (MEN-1) syndrome associated] remains scarce. In this study, the performance of 68 Ga-DOTATATE PET/CT was compared with contrast-enhanced computed tomography (CECT) and 68 Ga-NODAGA-Exendin-4 PET/CT (whenever available) in an endogenous hyperinsulinemic hypoglycemia (EHH) cohort. Retrospective audit. EHH patients [N = 36, lesions (n) = 49, final diagnosis: benign sporadic insulinoma (BSI) (N = 20), malignant insulinoma (N = 4, n = 14), MEN-1 syndrome associated insulinoma (N = 9, n = 15), Munchausen syndrome (N = 2) and drug-induced hypoglycemia (N = 1)] having both preoperative imaging modalities (CECT and 68 Ga-DOTATATE PET/CT). Per-lesion sensitivity (Sn) and positive predictive value (PPV) for histopathological diagnosis of insulinoma. Sn and PPV of 68 Ga-DOTATATE PET/CT were 67.3% and 89.2%; 55% and 100%; 85.7% and 100%; and 66.7% and 77% for overall EHH, BSI, malignant, and MEN-1 syndrome associated insulinoma cohorts respectively. Despite having comparatively lower sensitivity in BSI cohort, 68 Ga-DOTATATE PET/CT localized a pancreatic tail lesion missed by other modalities. 68 Ga-DOTATATE PET/CT had comparatively higher sensitivity in malignant insulinoma than BSI cohort. 68 Ga-DOTATATE PET/CT also paved the way for successful response to 177 Lu-based peptide receptor radionuclide therapy (PRRT). In MEN-1 cases, lower PPV as compared with BSI was due to uptake in non-insulinoma pancreatic neuroendocrine tumours (Pan-NET). 68 Ga-DOTATATE PET/CT has supplemental role in selected cases of BSI with negative and/or discordant results with CECT and 68 Ga-NODAGA-Exendin-4 PET/CT. In malignant insulinoma, 68 Ga-DOTATATE-PET/CT has an additional theranostic potential. Interference due to uptake in non-insulinoma Pan-NET in MEN-1 syndrome may hinder insulinoma localization with 68 Ga-DOTATATE-PET/CT.

Monday blues – Rare cause of hypoglycemia in a child with leukemia

Hypoglycemia in a child with acute lymphoblastic leukemia (ALL) often makes the clinician think of sepsis or metabolic disturbances due to relative adrenal insufficiency with steroid withdrawal. We report a rare scenario of drug-induced hypoglycemia in a child on treatment for ALL. Recurrent symptomatic episodes of hypoglycemia in a 4-year-girl on treatment for high-risk ALL were analyzed and it was surprising to note that the episodes were noted on early hours on Monday and Sunday nights. Detailed evaluation for the etiology and the workup was not contributory. With the background of drug history for ALL maintenance and occurrence of episodes on Mondays, possibility of drug-induced hypoglycemia secondary to cotrimoxazole was considered. Dose alteration for trimethoprim-sulfamethoxazole was considered stopping the drug is not feasible. Malnutrition was attributed as the coexisting risk factor in our child.

Management of type 2 diabetes for prevention of cardiovascular disease. An expert opinion of the Italian Diabetes Society

AimsType 2 diabetes mellitus is characterized by an increased risk of developing long-term cardiovascular complications. Several underlying mechanisms have been proposed for the diabetes-related increase in cardiovascular risk, i.e. chronic hyperglycemia, duration of the disease, drug-induced hypoglycemia, coexistence of multiple cardiovascular risk factors, etc. In the last few years, new pharmacological approaches capable of treating chronic hyperglycemia without increasing the risk of hypoglycemia have emerged for the treatment of diabetes. Data synthesisWith data mainly obtained from randomized controlled trials recruiting patients with type 2 diabetes in secondary prevention of cardiovascular disease, some of these newer antihyperglycemic drugs have shown to significantly reduce the risk of cardiovascular disease. In addition, the combined control of traditional cardiovascular risk factors, e.g. dyslipidemia, hypertension, etc., has demonstrated to be effective in reducing the burden of cardiovascular diseases in patients with type 2 diabetes. ConclusionsIn this document written by some experts of the Italian diabetes society (SID), we will focus our attention on oral antihyperglycemic agents for people with type 2 diabetes in primary or secondary prevention of cardiovascular disease, excluding for brevity the injection therapies for diabetes, such as insulin and glucagon-like peptide-1 receptor agonists.

Frequency and Predisposing Factors for Drug-Induced Hypoglycemia in Patients with Type-2 Diabetes Mellitus: A Comment.

Frequency and Predisposing Factors for Drug-Induced Hypoglycemia in Patients with Type-2 Diabetes Mellitus: A Comment.

Comparative study of hypoglycaemia induced by opioids. Is it a class effect?

ABSTRACTObjective: Drug-induced hypoglycaemia has been described with the use of tramadol and methadone. The authors aimed to determine if drug-induced hypoglycaemia could be a class effect for opioids.Methods: The authors performed a disproportionality analysis in VigiBase®, the WHO global individual case safety report database with nine opioids (codeine, fentanyl, hydromorphone, methadone, morphine, oxycodone, tramadol, buprenorphine and nalbuphine) using the broad Standardised MedDRA Query for hypoglycaemia. The authors also carried out a descriptive study of opioid-induced hypoglycaemia in the French PharmacoVigilance DataBase (FPVDB) using the MedDRA Preferred Term ‘hypoglycaemia’.Results: The global adjusted Reporting Odds Ratio (aROR) value for the 9 opioids was 1.53 (95% CI 1.52–1.54). The aROR ranged from 1.09 to 1.97 depending on the opioid, but all were statistically significant. A sex ratio of 0.74 was found for the reports of opioid-induced hypoglycaemia in Vigibase®. The authors also found 133 reports of hypoglycaemia in the FPVDB related to opioids. Among the reports, 55 were glycaemic imbalances in diabetics occurring shortly after the start of opioid treatment.Conclusion: This work highlighted a significant association between all opioids and hypoglycaemia, thereby indicating that opioid-induced hypoglycaemia is probably a class effect. Women and/or diabetics seem to be more at risk for developing opioid-induced hypoglycaemia.

Frequency and Predisposing Factors for Drug-Induced Hypoglycemia in Patients with Type-2 Diabetes Mellitus.

Objective:Hypoglycemia is the most common complication of the treatment for diabetes mellitus. Various factors predispose an individual for drug-induced hypoglycemia. The aim of this study was to explore the relative frequency and likely predisposing factors for drug-induced hypoglycemia among type-2 diabetic patients in the United Arab Emirates (UAE).Methods:In this cross-sectional survey-based study which was conducted from February to April 2018 in two local community pharmacies in the UAE, diabetic patients underwent a structured interview on their diabetes mellitus status and management and specific open-ended questions related to hypoglycemic symptoms that they might have experienced and the occurrence of symptoms. Collected data were used to estimate the relative frequency of drug-induced hypoglycemia and to identify the probable predisposing factors and their contribution in causing hypoglycemia using relative risk, Chi-square test, and Fisher's exact test.Findings:The relative frequency of drug-induced hypoglycemia in our study was 46.25%. Patients' age of ≥65 years, duration of diabetes mellitus for more than 1 year, patients with more than one comorbid condition, and patients using more than one antidiabetic medication were predisposing for developing drug-induced hypoglycemia.Conclusion:The relative frequency of drug-induced hypoglycemia in a nontrial environment which lacks the special cares routinely provided in drug development clinical trials is high. We suggest that more attention should be paid to identify, prevent, and manage drug-induced hypoglycemia in type-2 diabetic patients who have more than 1 year of diabetes, more than one comorbidity, using more than one antidiabetic medication, and elderly.

Development and validation of an automated algorithm for identifying patients at high risk for drug-induced hypoglycemia

Hypoglycemia is one of the most concerning adverse drug events in hospitalized patients. Using information from institutional electronic health records, we aimed to develop dynamic predictive models to identify patients at high risk for hypoglycemia during antihyperglycemic therapy. The study population consisted of 21,840 patients who received antihyperglycemic medication on any of the first 5 hospital days (the "risk model days") at 2 large hospitals. Data on candidate predictors were extracted from discrete electronic health record fields to construct models for predicting hypoglycemia within 24 hours after each risk model day. Final models were internally validated by replication in 100 bootstrap samples and reapplying model parameters to the original risk population. The development and validation sample included 60,762 risk model days followed by 1,256 days with hypoglycemic events (2.07 events per 100 risk model days). The days 3, 4, and 5 models presented similar associations between predictors and the risk of hypoglycemia and were therefore collapsed into a single model. The strongest hypoglycemia risk factors across all 3 risk periods (day 1, day 2, and days 3-5) were blood glucose (BG) fluctuations, BG trend, history of hypoglycemia, lower body weight, lower creatinine clearance, use of long-acting or high-dose insulin, and sulfonylurea use. C statistics for the 3 models ranged from 0.844 to 0.887. Depending on the model used, risk scores in the upper 90th percentile predicted 48.5-63.1% of actual hypoglycemic events. It was estimated that by targeting only patients in the upper 90th percentile, providers would need to intervene during fewer than 9 admissions to prevent 1 hypoglycemic event. The developed prediction models were found to have excellent discriminative validity and good calibration, allowing clinicians to focus interventions on a select high-risk population in which the majority of hypoglycemic events occur.

Adjustment for time-dependent unmeasured confounders in marginal structural Cox models using validation sample data.

Large databases used in observational studies of drug safety often lack information on important confounders. The resulting unmeasured confounding bias may be avoided by using additional confounder information, frequently available in smaller clinical "validation samples". Yet, no existing method that uses such validation samples is able to deal with unmeasured time-varying variables acting as both confounders and possible mediators of the treatment effect. We propose and compare alternative methods which control for confounders measured only in a validation sample within marginal structural Cox models. Each method corrects the time-varying inverse probability of treatment weights for all subject-by-time observations using either regression calibration of the propensity score, or multiple imputation of unmeasured confounders. Two proposed methods rely on martingale residuals from a Cox model that includes only confounders fully measured in the large database, to correct inverse probability of treatment weight for imputed values of unmeasured confounders. Simulation demonstrates that martingale residual-based methods systematically reduce confounding bias over naïve methods, with multiple imputation including the martingale residual yielding, on average, the best overall accuracy. We apply martingale residual-based imputation to re-assess the potential risk of drug-induced hypoglycemia in diabetic patients, where an important laboratory test is repeatedly measured only in a small sub-cohort.

Isolation and characterization of non-sulfated and sulfated triterpenoid saponins from Fagonia indica

Seven previously undescribed, sulfated triterpenoid glycosides, named nayabin A-G along with a known triterpenoid glycoside were isolated from the whole plant of Fagonia indica. Their structures were elucidated through spectral studies including 1D- (1H and 13C), 2D-NMR spectroscopy (HSQC, HMBC, COSY and NOESY), and mass spectrometry (ESI-MS/MS). β-D-Glucopyranosyl 3β-hydroxy-23-O-β-D-glucopyranosyloxy-taraxast-20-en-28-oate, a known compound exerts glucose-dependent insulin secretory activity, which seems to exhibit a decreased risk of drug-induced hypoglycemia and may offer distinct advantages as anti-diabetic agent.

Impact of drugs on hypoglycemia in hospitalized patients

Hypoglycemia is a life-threatening condition that can be encountered during hospitalization. Several risk factors have been identified such as critical illness or general anesthesia. Drug-induced hypoglycemia is classically related to several antidiabetic drugs. However, a growing number of reports associating hypoglycemia to non-antidiabetic drugs have been published recently, suggesting that this side effect can be underreported. The aim of this study was to investigate the potential risk between prescribed drugs and hypoglycemia episode during hospitalization. Patients from a regional hospital admitted between 2013 and 2015 were analyzed. Point of care blood glucose values and prescribed drugs were extracted from electronic records. Hypoglycemia cases were defined as having at least one hypoglycemic event (random glucose value < 3.8 mmol/L) and normoglycemic cases as having all fasting glucose concentrations during hospitalization ranging between 4.5 and 5.8 mmol/L. Patients who did not meet these criteria were excluded for analysis. Cox proportional hazard models were used to assess the first event of hypoglycemia after admission. Multivariate logistic regressions were carried out to identify drugs associated with hypoglycemia. Three hundred and forty-nine patients (53% males; median age = 74 years) were included in the analysis, among them 47 (13%) had at least one hypoglycemia event and 302 (87%) were normoglycemic. No differences in age and gender were found between the two groups. Patients with a hypoglycemic event had a longer duration of hospitalization (median = 11 vs. 7 days, P < 0.01) and were more prone to polymedication than normoglycemic patients (median = 11 vs. 8 drugs, P < 0.01). One hundred and fifty-four patients (44%) had at least one antidiabetic agent, among them 58 patients (38%) had at least one drug-drug interaction (DDI) with a non-antidiabetic drug resulting to a possible decrease of blood glucose concentration. No influence of DDI on hypoglycemia rate was observed. The number of prescribed antidiabetic agents was associated with an increased risk of hypoglycemia during hospitalization (hazard ratio = 2.5, IC95 = 1.7–3.7, P < 0.01). After adjusting by gender, age and insulin use, morphine was found associated with hypoglycemia (odds-ratio = 3.0, IC95 = 1.1–8.1, P = 0.03). Trends (P = [0.05–0.1]) were observed for torasemide, vancomycin, escitalopram and paracetamol. Patients with antidiabetic drugs are at risk for hypoglycemia event and should thus be closely monitored during hospitalization. Several drugs were found to be marginally associated with hypoglycemia events and should be replicated in further studies.

Unusual antithyroid drug-induced hypoglycemia

Insulin autoimmune syndrome is defined as the occurrence of spontaneous hypoglycemia attacks with high titers of anti-insulin autoantibodies in patients with no previous exposure to insulin. This rare syndrome has mostly been reported from the Japanese population and is frequently associated with other autoimmune conditions and certain drugs, especially those containing a sulfhydryl group. Most cases undergo spontaneous remission following removal of the offending drug. We hereby describe the case of a female who developed this rare syndrome following intake of carbimazole for Graves' disease.

Application of dynamic glucose monitoring in the diagnosis and differential diagnosis of hypoglycemia

Objective To analyze the characteristics of dynamic blood glucose in hypoglycemia patients with different causes and explore the application value of dynamic glucose monitoring system (DGMS) in the diagnosis and differential diagnosis of hypoglycemia. Methods We used DGMS to monitor the blood glucose levels of 20 hypoglycemia patients for 3-6 days, including 6 cases of insulinoma, 7 cases of reactive hypoglycemia, 2 cases of autoimmune hypoglycemia, 3 cases of islet cell hyperplasia, 1 case of drug-induced hypoglycemia, 1 case of congenital hyperinsulinism. The blood glucose profiles of hypoglycemia patients with different causes were compared. Results The average monitoring duration was (88.9±10.8)hours. 38-936 points of hypoglycemia were detected in these patients with hypoglycemia. The average blood glucose of patients of each cause, in the order from low to high, were: congenital hyperinsulinism [(2.97±0.59)mmol/L], islet cell hyperplasia [(4.83±1.32)mmol/L], insulinoma [(4.87±1.37)mmol/L], drug-induced hypoglycemia [(5.98±0.8)mmol/L], reactive hypoglycemia [(6.38±1.99)mmol/L], and autoimmune hypoglycemia [(7.63±2.67)mmol/L]. The constituent ratio of hypoglycemia from low to high were: autoimmune hypoglycemia and drug-induced hypoglycemia (0%), reactive hypoglycemia [0.5% (0.0%, 1.6%), insulinoma [9.0% (5.2%, 16.3%), islet cell hyperplasia [9.5% (1.1%, 14.2%), congenital hyperinsulinism (58.5%). In terms of the blood glucose profiles in day and night, the night blood glucose levels were lower than those in daytime in insulinoma [(5.16±1.37)mmol/L vs. (4.44±1.24)mmol/L], reactive hypoglycemia [(6.93±2.19)mmol/L vs. (5.57±1.25)mmol/L], autoimmune hypoglycemia [(8.08±2.79)mmol/L vs. (6.95±2.31)mmol/L], islet cell hyperplasia [(5.23±1.31)mmol/L vs. (4.11±1.00)mmol/L] and congenital hyperinsulinism [(3.06±0.57)mmol/L vs. (2.83±0.59)mmol/L] (all P<0.05); while the daytime blood glucose level was lower than that at night in drug-induced hypoglycemia [(5.90±0.81)mmol/L vs. (6.11±0.77)mmol/L, P<0.05]. 62.2% and 78.9% of the hypoglycemia episodes happened at night in patients with insulinoma and islet cell hyperplasia, and 43.2% at night in patients with congenital hyperinsulinism. The highest standard deviation of blood glucose (2.67 mmol/L), largest amplitude of glycemic excursions (9.2 mmol/L)and coefficient of variation (35%) were found in patients with autoimmune hypoglycemia. The largest range of blood glucose (20.4 mmol/L) was found in patients with reactive hypoglycemia. The day-night differences in coefficient of variation (31.6% vs. 22.4%) and range of blood glucose (20.4 mmol/L vs. 6.8 mmol/L) were most prominent in patients with reactive hypoglycemia. Conclusion The dynamic monitoring of blood glucose and the analysis of the parameters such as average blood glucose, blood glucose profiles and variability of blood glucose may be helpful for the diagnosis of hypoglycemia and differential diagnosis of causes of hypoglycemia. Key words: Hypoglycemia; Insulinoma; Dynamic glucose monitoring system; Continuous glucose monitoring system; Reactive hypoglycemia; Differential diagnosis

Preventing Unnecessary Costs of Drug-Induced Hypoglycemia in Older Adults with Type 2 Diabetes in the United States and Canada.

BackgroundThe costs of drug-induced hypoglycemia are a critical but often neglected component of value-based arguments to reduce tight glycemic control in older adults with type 2 diabetes.MethodsAn economic (decision-tree) analysis compared rates, costs, quality-adjusted life-years, and incremental costs per quality-adjusted life-year gained associated with mild, moderate and severe hypoglycemic events for 6 glucose-lowering medication classes in type 2 diabetic adults aged 65–79 versus those 80 years and older. The national U.S. (Center for Medicare Services) and Canadian public health payer perspectives were adopted.FindingsIncidence rates of drug-induced hypoglycemia were the highest for basal insulin and sulfonylureas: 8.64 and 4.32 events per person-year in 65–79 year olds, and 12.06 and 6.03 events per person-year for 80 years and older. In both the U.S. and Canada, metformin dominated sulfonylureas, basal insulin and glucagon-like peptide1 receptor agonists. Relative to sulfonylureas, thiazolidinediones had the lowest incremental cost-effectiveness ratios in the U.S. and dominated sulfonylureas in Canada for adults 80 years and older. Relative to sulfonylureas, dipeptidyl peptidase4 inhibitors were cost-effective for adults 80 years and older in both countries, and for 65–79 year olds in Canada. Annual costs of hypoglycemia for older adults attaining very tight glycemic control with the use of insulin or sulfonylureas were estimated at U.S.$509,214,473 in the U.S. and CAN$65,497,849 in Canada.ConclusionsOptimizing drug therapy for older type 2 diabetic adults through the avoidance of drug-induced hypoglycemia will dramatically improve patient health while also generating millions of dollars by saving unnecessary medical costs.

Glibenclamide-induced profound hypoglycaemic crisis: a case report

The value of sulphonylureas in the long-term treatment of type II diabetes has been questioned. The potential benefits of an antidiabetic drug must be carefully weighed against the risk of developing hazardous adverse effects like hypoglycaemia. We present drug-induced hypoglycaemia in a 77-year-old Pakistani male who had hypertension, type II diabetes and renal parenchymal disease (grade I), presented to the emergency department complaining of a 1-day history of fever, loose motions and drowsiness. His fever was low grade, intermittent, and not associated with rigors and chills. He had four episodes of watery stools for 1 day, with no associated vomiting but with drowsiness. He was aphasic, unable to walk and did not recognize his family members. The patient was taken to his local doctor who found him to be hypoglycaemic, with a blood sugar of 45 mg/dl. He was managed with intravenous (IV) dextrose and referred to the hospital. Hypoglycaemia is perhaps the most widespread and underreported complication of oral hypoglycaemic agents and may lead to overwhelming morbidity and mortality. Patient evaluation and proper counselling may help in identifying patients at greatest risk and avoid complications associated with these commonly prescribed drugs.