Hypoglycemia & Medication Considerations in Older Adults with Diabetes

Announcer:
Welcome to Diabetes Discourse on ReachMD. On this episode, sponsored by Lilly, Dr. Rozalina G. McCoy, an endocrinologist, primary care physician, and a National Institutes of Health-funded health services researcher discusses hypoglycemia and shares medication considerations for older adults with diabetes. Let’s hear from her now.

Dr. McCoy:
So, when patients with diabetes experience hypoglycemia, there are several things that I really try to do in the clinic when I see them. First, it’s really important to understand exactly the circumstances that led to their hypoglycemic event.

So, I have my patients walk me through what they did when they experienced the hypoglycemic event. Make sure that they check their blood sugar to verify that it was hypoglycemia and monitoring blood sugar is very important because there are so many things that can mimic symptoms of hypoglycemia that may not be hypoglycemia. We also talk about how patients treated it. We also stress that hypoglycemia is a low blood sugar problem, it's not a low fat or a low protein problem, so they really need to eat carbs, not a Snickers bar or a, you know, candy with a lot of fat that is gonna delay absorption, not a cheese stick, they really need to eat fast-acting carbohydrates.

And finally, for patients who have had severe hypoglycemia, so anything with loss of consciousness or seizure, anything where they can’t safely take oral carbohydrates to reverse, make sure that we give patients a glucagon prescription.

For older patients with diabetes who are experiencing hypoglycemia, one of the biggest things that I worry about is impaired awareness of hypoglycemia, whether it is because they have had diabetes for a very long time or they are taking medications that contribute to hypoglycemia unawareness, or they may have cognitive impairment or comorbidities that predispose them to impaired hypoglycemia awareness. So, always ask patients about, how often can they tell that their blood sugar is dropping and how low does the blood sugar have to get for them to feel symptoms of hypoglycemia. If patients endorse impaired awareness of hypoglycemia, which unfortunately is very common in this population, there are validated diabetes self-management education approaches that can restore, at least partially awareness of hypoglycemia and prevent recurrent events.

The other thing in the older population is to look at all of the other medications that they’re taking, make sure that they don’t, kind of, contribute to hypoglycemia or hypoglycemia-unawareness. Most often this is things like beta-blockers in patients with heart disease. And then finally, again, especially for older adults, try to simplify their treatment regimen as much as possible. So, that means, you know, trying to use medications with the lowest risk for hypoglycemia, avoiding a combination of insulin and sulfonylurea therapy, trying to maximize non-insulin medication use, especially in patients who are already on basal insulin, before intensifying to intensive insulin therapy. And then also for patients treated with basal insulin, avoiding over basalization, which is when patients are getting too much basal insulin and inappropriately trying to cover their meals with basal insulin. That’s very common and, and unfortunately, one of the most common causes for hypoglycemia especially at night, that we may not detect in our patients with type 2 diabetes who are not wearing continuous glucose monitoring.

I think to make sure that our treatment decisions are really appropriate for our older patients who have experience hypoglycemia, it’s important to talk to our patients and know what their life is like and to make their diabetes treatment regimen fit into their life, and not the other way around. So, making sure we know when and what, and how they’re eating and timing their medication to that. Making sure that our patients are monitoring their blood sugar levels appropriately, given their treatment regimen. Addressing food insecurity, which is very common, unfortunately in our older patients. And using safe medications that are appropriate for them. Trying to maximize non-insulin medications, dosing them appropriately. Avoiding sliding scale insulin. I think most of the things that cause hypoglycemia are things that we do to our patients, so it’s important to just talk to them and figure out what their life is like and make those decisions together to make sure they work for them.

Announcer:
This episode of Diabetes Discourse was sponsored by Lilly. To revisit any part of this discussion and to access other episodes in this series, visit ReachMD.com/DiabetesDiscourse, where you can Be Part of the Knowledge. Thanks for listening.