Is Reducing Serious Hypoglycemia one of your PIPs?

by Timothy Gieseke MD, CMD

This year, our state QIO, HSAG, has been sponsoring webinars that help our facilities reduce the risk for incurring a readmission payment penalty, when the financial penalties go live January 1, 2019.  I will be presenting the webinar on June 27th for reducing the risk of serious hypoglycemia. You can register at:

While there are many traditional things we can do to identify and manage this risk, our tool bag for safely lowering the risk has increased in recent years with the addition of SLG2’s and Incretin Receptor Agonists.  Both classes of medicines have a much lower risk of inducing serious hypoglycemia then oral sulfonylureas or insulin and both may help reduce weight and may reduce the risk of macro-vascular disease. Empagliflozin (Jardiance) and lirglutide (Victoza) now have an FDA indication for macrovascular risk reduction.  Empagliflozin is ineffective if EGFR is < 30, but liraglutide has no dose adjustment for renal or hepatic disease. The expense of both of these medicines is similar to the now high cost of our insulins.

In this January’s ADA 2018 Standard of Care recommendations for diabetes, both classes of meds are now recommended after metformin for persons with diabetes who have established or high risk for cardiovascular disease.  The AACE 2018 Guidelines also make this recommendation.

I recently had a post-acute rehabilitation admission, where the risk of inducing hypoglycemia was very real.  This ~60 y/o person had developmental delay and long standing paranoid schizophrenia with slowly worsening cognition.  His diabetes had been controlled for 10 years with metformin and his mental health was stable with the support of a mental health telemedicine support service. From his family’s perspective, this was wonderful, since it allowed this patient to live safely alone in an apartment and explore the community.  However, his diabetes insidiously decompensated eventuating in a hospitalization for uncontrolled hyperglycemia (A1C 10.9) and dehydration. His family was very reluctant to add insulin to metformin as a part of his care plan even though this is the usual approach recommended by the ADA and AACE Guidelines. His siblings were concerned that he would not be able to self-manage insulin or FSG checks.  This would mean an end to his former ideal living situation. While I was empathetic about their concern for his freedom and quality of life, I did convince them to allow Lantus once daily in addition to his metformin to minimize insulin resistance induced by his hyperglycemia and allow him to regain his strength and independence. As those benefits developed, I added liraglutide sq daily, stopped his Lantus, and have achieved near normal glycemic control without any “lows”. Liraglutide in combination with metformin has so low a risk for hypoglycemia, that FSG testing will only be needed in the future to insure adequate glycemic control.  I am hoping to get a TAR for dulaglutide (Trulicity), which is given sq once a week. With this change, he should be able to discharge back to his former situation with family, or family hired caregiver, giving the weekly injection and performing an occasional FSG check.

For more ideas on how to reduce your facilities risk for serious hypoglycemic events, sign up for the June 27, 2018 HSAG Webinar.

Stay tuned to the WAVE.