Shorr R I, Ray W A, Daugherty J R, Griffin M R
Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tenn., USA.
Arch Intern Med. 1997;157(15):1681-6.
Our knowledge about the risk of hypoglycemia associated with diabetes treatment is derived from studies that often exclude frail, elderly persons.
To determine the incidence and risk factors for developing serious hypoglycemia among older persons using sulfonylureas or insulin.
We conducted a population-based, retrospective cohort study of 19932 Tennessee Medicaid enrollees, aged 65 years or older, who used insulin or sulfonylureas from 1985 through 1989. The main end point was serious hypoglycemia defined as a hospitalization, emergency department admission, or death associated with hypoglycemic symptoms and a concomitant blood glucose determination of less than 2.8 mmol/L (< 50 mg/dL).
We identified 586 persons with a first episode of serious hypoglycemia during 33,048 person-years of insulin or sulfonylurea use. The crude rates (per 100 person-years) of serious hypoglycemia were 1.23 (95% confidence interval [CI], 1.08-1.38) in users of sulfonylureas and 2.76 (95% CI, 2.47-3.06) among insulin users. Recent hospital discharge was the strongest predictor of subsequent hypoglycemia in older persons with diabetes. The adjusted relative risk of serious hypoglycemia occurring in days 1 through 30 after hospital discharge was 4.5 (95% CI, 3.5-5.7) compared with the risk associated with a hypoglycemic event occurring 366 or more days after hospital discharge. Other independent risk factors included advanced age (relative risk, 1.8; 95% CI, 1.4-2.3), black race (relative risk, 2.0; 95% CI, 1.7-2.4), and use of 5 or more concomitant medications (relative risk, 1.3; 95% CI, 1.1-1.5).
In this population, the incidence of serious hypoglycemia is approximately 2 per 100 person-years, suggesting that many older adults can be safely treated with hypoglycemic drugs. Frail, elderly persons--the oldest-old, those using multiple medications, and those who are frequently hospitalized--are at a higher risk for drug-associated hypoglycemia. Such individuals may benefit from intensive education about the symptoms of hypoglycemia and close monitoring for adverse events related to diabetes treatment.
我们关于糖尿病治疗相关低血糖风险的认知源于一些通常排除了体弱老年人的研究。
确定使用磺脲类药物或胰岛素的老年人发生严重低血糖的发生率及风险因素。
我们对19932名田纳西医疗补助计划参保者进行了一项基于人群的回顾性队列研究，这些参保者年龄在65岁及以上，在1985年至1989年期间使用胰岛素或磺脲类药物。主要终点是严重低血糖，定义为因低血糖症状住院、急诊就诊或死亡，同时血糖测定低于2.8 mmol/L（<50 mg/dL）。
在使用胰岛素或磺脲类药物的33048人年中，我们确定了586例首次发生严重低血糖的患者。磺脲类药物使用者严重低血糖的粗发病率（每100人年）为1.23（95%置信区间[CI]，1.08 - 1.38），胰岛素使用者为2.76（95%CI，2.47 - 3.06）。近期出院是糖尿病老年人后续发生低血糖的最强预测因素。与出院366天或更长时间后发生低血糖事件的风险相比，出院后1至30天发生严重低血糖的调整后相对风险为4.5（95%CI，3.5 - 5.7）。其他独立风险因素包括高龄（相对风险，1.8；95%CI，1.4 - 2.3）、黑人种族（相对风险，2.0；95%CI，1.7 - 2.4）以及使用5种或更多合并用药（相对风险，1.3；95%CI，1.1 - 1.5）。
在该人群中，严重低血糖的发生率约为每100人年2例，这表明许多老年人可以安全地使用降糖药物治疗。体弱的老年人——年龄最大的老年人、使用多种药物的老年人以及经常住院的老年人——发生药物相关低血糖的风险更高。这类个体可能会从关于低血糖症状的强化教育以及对糖尿病治疗相关不良事件的密切监测中受益。
