Category: Federal Forum Posters
Purpose: Hypoglycemia is one of the most common side effects of antidiabetic medications. Repeated hypoglycemic events can lead to negative physiological impacts on patients and even increased risk of mortality. Studies on the veteran population have identified stringent hemoglobin A1c (HbA1c) goals potentially contributing to hypoglycemic events. This often results from HbA1c goals that are not tailored to a patient’s life expectancy, microvascular complications, and duration of diabetes. The purpose of this project was to determine if HbA1c goal was loosened for veterans who had multiple episodes of hypoglycemia that resulted in an adjustment of antidiabetic therapy.
Methods: This investigation utilized the PhARMD tool (Pharmacists Achieve Results with Medication Demonstration), which provides documentation of pharmacist-implemented medication interventions on the VA computerized patient record system (CPRS). Using this tool, data can be pooled for pre-specified interventions that have occurred over a specific time period. For this investigation, the tool was utilized to identify any medication adjustment made by a pharmacist in response to a hypoglycemic event during a diabetes clinic visit. The PhARMD tool identified 127 patients for whom such an intervention occurred within a nine-month period. A retrospective chart review was conducted to identify events that occurred two or more times within a three-month time frame. This time frame was selected so that only hypoglycemic events occurring in close proximity were evaluated for possible adjustments in HbA1c goal. Each hypoglycemic event was assessed to determine the cause, adjustments in antidiabetic therapy, and any changes in HbA1c goals that resulted from repeated hypoglycemic events. The patient’s baseline HbA1c goal was also analyzed to determine if it was appropriate based on estimated life expectancy, microvascular complications, and duration of diabetes as recommended by the VA Department of Defense (DoD) guidelines.
Results: Of the 127 patients initially identified, 43 experienced at least two hypoglycemic episodes requiring medication adjustment within a three-month period. There were a total 115 events which occurred in the 43 patients included in data analysis. Patients had varying total numbers of events including 25 patients with two events, 17 with three or more, and one patient with seven episodes of hypoglycemia requiring medication intervention. The most common identifiable cause of hypoglycemia was decreased carbohydrate intake, but in the majority of cases, the cause was undetermined. The most common intervention was a decrease in basal insulin dose; whereas bolus insulin therapy was most likely to be discontinued. Of the 43 patients, three had a change in HbA1c goal as a result of repeated hypoglycemic events. One patient had a documentation of discussion regarding possible adjustment of HbA1c goal, however no changes were made.
Conclusion: This investigation determined that, in most instances, repeated events of hypoglycemia leading to a medication adjustment did not result in a re-assessment of HbA1c goals. Periodic re-evaluation of HbA1c goal may help avoid detrimental and potentially life-threatening hypoglycemic events. As recommended by the VA DoD guidelines for diabetes, changes in life expectancy, microvascular complications, and duration of diabetes are important factors to assess when determining an appropriate HbA1c goal and can be helpful in preventing hypoglycemic events.
Sharon Maria Mathew– Pharmacy Resident, Grand Island VA Hospital, Grand Island, NE