胰岛素相关低血糖每年引起10万例次急诊

《美国医学会杂志•内科学》(JAMA Internal Medicine)3月10日在线发表的一项研究显示，与2型糖尿病“过度严格”胰岛素控制相关的重度低血糖每年导致近10万例次急诊就诊和3万例次住院，并且特别常见于老年患者(JAMA Intern. Med. 2014 March 10 [doi:10.1001/jamainternmed.2014.136])。

疾病控制与预防中心医疗保健质量促进科的Andrew I. Geller医生及其同事对国家电子损伤监测系统-合作药物不良事件监测项目中的国家代表性医院样本数据进行分析发现，5年期间2型糖尿病成人每年因低血糖相关休克、意识丧失、痫样发作、损伤或跌倒或精神状态改变而进行97,648例次急诊就诊。大部分病例的血糖水平≤50 mg/dl。

在年龄≥80岁的患者中，胰岛素控制相关重度低血糖的发生率为34.9/1,000例胰岛素治疗患者。相比之下，在45~64岁患者仅为13.7/1,000例胰岛素治疗患者。老年患者需急诊就诊的几率是较年轻患者的2倍以上，并且前者需住院的几率是后者的近5倍。

最常见的诱发因素是“饮食相关意外事件”，如不能在使用速效胰岛素后不久进食，或不能调整胰岛素方案以应对错过饮食或餐量非常小的情况。低血糖也常发生于患者使用错误的胰岛素剂量或错误的胰岛素产品(通常使用速效胰岛素而非长效胰岛素)之后。

研究者表示，这些数据可能低估了低血糖事件的总体负担，因为虽然低血糖是急诊就诊的常见原因，但通常在急诊室以外就被处理了。以下患者未被计算在内：无症状低血糖患者、低血糖发作未导致急诊治疗的患者，以及在送急诊途中死亡的患者。

研究者声明无经济利益冲突。

随刊述评：药企是胰岛素过度使用的积极推广者

加州大学老年病科的Sei J. Lee医生表示，重度胰岛素相关低血糖不仅具有“很常见”的特点，而且与大部分其他急诊就诊原因的区别还在于其通常为医源性(JAMA Intern. Med. 2014 March 10 [doi:10.1001/jamainternmed.2013.13307])。

过去10年内胰岛素使用率增加50%，这引发了低血糖事件的激增。胰岛素使用率的增加可归因于药企过于积极鼓励患者和医生进行强化降糖治疗。药企塑造了当前严格血糖控制的流行观点，这一观点导致了胰岛素的过度使用。

我们不应认为目前的低血糖发生率是不可避免的，或将其视为可以接受的治疗代价。相反，我们应开始使用多管齐下的方法来减少胰岛素的过度使用，并最大程度地降低低血糖风险。

Lee医生声明无相关经济利益冲突。

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By: MARY ANN MOON, Clinical Endocrinology News Digital Network

Severe hypoglycemia related to overly "tight" insulin control for type 2 diabetes prompts nearly 100,000 emergency department visits and 30,000 hospitalizations each year and is particularly common among older patients, according to a report published online March 10 in JAMA Internal Medicine.

In an analysis of data from a nationally representative sample of hospitals in the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project, researchers estimated that 97,648 ED visits occurred annually during a 5-year period among adults with type 2 diabetes who presented with hypoglycemia-related shock, loss of consciousness, seizure, injury or fall, or altered mental status. Most cases involved blood glucose levels of 50 mg/dL or less, said Dr. Andrew I. Geller of the division of healthcare quality promotion at the Centers for Disease Control and Prevention, Atlanta, and his associates.

The case rate was 34.9 per 1,000 insulin-treated patients among those aged 80 years and older. In comparison, the rate was only 13.7 per 1,000 among those aged 45-64 years. Older patients were more than twice as likely as younger ones to require an ED visit and nearly five times as likely to require hospitalization, Dr. Geller and his associates said (JAMA Intern. Med. 2014 March 10 [doi:10.1001/jamainternmed.2014.136]).

The most common precipitating factor was "meal-related misadventure" – failing to eat shortly after taking rapid-acting insulin or failing to adjust the insulin regimen to account for a missed meal or a very small meal. Hypoglycemia also was frequently preceded by the patient taking the wrong dose of insulin or the wrong insulin product, usually taking rapid-acting insulin instead of long-acting insulin.

"These data probably underestimate the total burden of hypoglycemic events because hypoglycemia, although a frequent cause of [emergency medical services] calls, is most often cared for outside the ED setting. Patients who have hypoglycemia unawareness and whose episodes do not result in EMS or ED care [were] not counted, nor [were] those who died en route to the ED," they added.

No financial conflicts of interest were reported.

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Drug industry fuels overuse of insulin

Severe insulin-related hypoglycemia is not just "remarkably common," it also differs from most other causes of emergency department visits in that it is almost always iatrogenic, said Dr. Sei J. Lee.

And as noted by Dr. Geller and his associates, the 50% increase in insulin use during the past decade is fueling this epidemic of hypoglycemia. That, in turn, can be attributed to the drug industry’s "all-too-effective efforts ... to encourage patients and providers to intensify glycemic treatment." Pharmaceutical companies have "shaped the current widespread belief in tight glycemic control that has led to aggressive prescribing" of insulin, he said.

"We should not accept the current rates of hypoglycemia as inevitable" or as an acceptable price to pay for treatment, Dr. Lee said. "Rather, we should begin using a multipronged approach to decrease the overuse of insulin and minimize the risk of hypoglycemia."

Dr. Lee is with the division of geriatrics at the University of California and the Veterans Affairs Medical Center, both in San Francisco. He reported no relevant financial conflicts of interest. These remarks were taken from his invited commentary accompanying Dr. Geller’s report (JAMA Intern. Med. 2014 March 10 [doi:10.1001/jamainternmed.2013.13307]).