|Year : 2018 | Volume
| Issue : 2 | Page : 57-65
Epidemiology of hypoglycemia among ambulatory Type 2 diabetic patients in a primary care clinic of a tertiary hospital in Southeastern Nigeria
Gabriel Uche Pascal Iloh1, Agwu Nkwa Amadi2
1 Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State, Nigeria
2 Department of Public Health, Federal University of Technology, Owerri, Imo State, Nigeria
|Date of Submission||31-Mar-2017|
|Date of Acceptance||18-Jul-2018|
|Date of Web Publication||13-Aug-2018|
Dr. Gabriel Uche Pascal Iloh
Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State
Source of Support: None, Conflict of Interest: None
Aim: The study was aimed at describing the epidemiology of hypoglycemia among ambulatory type 2 diabetic patients in a primary care clinic in Eastern Nigeria. Materials and Methods: A cross-sectional descriptive study was carried out on 145 type 2 diabetic patients in a primary care clinic in Nigeria. Data were collected using pretested, structured, and interviewer-administered questionnaire containing information on relevant epidemiological variables. Experience of hypoglycemia was defined as self-reported symptoms of hypoglycemia in the previous 1 year. Results: The age of type 2 diabetic patients ranged from 32 to 78 years with mean age of 44 ± 10.2 years. There were 59 (40.7%) males and 86 (59.3%) females. The prevalence of hypoglycemia was 35.2%. Hypoglycemia occurred predominantly among the elderly (72.5%), male gender (54.9%), outside home environment (72.5%), during the daytime (82.4%), duration of diabetes ≤1 year (58.8%), and patients on insulin secretagogues alone (46.2%). The most common symptom was dizziness (76.5%). Experience of hypoglycemia was significantly associated with elderly age (P = 0.025), duration of diabetes ≤1 year (P = 0.021), and use of insulin secretagogues alone (P = 0.043). The most significant predictor of hypoglycemic events was use of insulin and insulin secretagogues (odds ratio = 3.15 [1.74–5.66]; P = 0.002). Type 2 diabetic patients on insulin and insulin secretagogues were three times more likely to experience hypoglycemic events compared to their counterparts who were on insulin sensitizers. Conclusion: The study has shown variable epidemiology of hypoglycemia. The incident occurred predominantly among the elderly, male gender, during daytime, outside home environment, duration of diabetes ≤1 year, and patients on insulin and insulin secretagogues. Interventional measures for hypoglycemia should consider relevant epidemiological factors that predispose to hypoglycemia.
Keywords: Adult Nigerians, diabetes, epidemiology, hypoglycemia, primary care
|How to cite this article:|
Iloh GU, Amadi AN. Epidemiology of hypoglycemia among ambulatory Type 2 diabetic patients in a primary care clinic of a tertiary hospital in Southeastern Nigeria. J Health Res Rev 2018;5:57-65
|How to cite this URL:|
Iloh GU, Amadi AN. Epidemiology of hypoglycemia among ambulatory Type 2 diabetic patients in a primary care clinic of a tertiary hospital in Southeastern Nigeria. J Health Res Rev [serial online] 2018 [cited 2021 Apr 15];5:57-65. Available from: https://www.jhrr.org/text.asp?2018/5/2/57/238864
| Introduction|| |
Diabetes mellitus is a chronic endocrine-related disorder where chronic hyperglycemia has occurred to the extent that it may have adverse effects on health leading to reduced life expectancy and/or increase medical problems., Diabetes was once thought to be the health problem of affluent Western countries but now has increased in prevalence in most developing countries and resulted from change in physical inactivity, dietary habit, and other lifestyles factors.,,, The increasing prevalence of diabetes mellitus worldwide is of great concern to the World Health Organization and the rising burden increases pressure on ill-equipped health-care delivery system in developing nations like Nigeria, particularly during diabetes-related emergencies and perturbations such as hypoglycemia.
Hypoglycemia in type 2 diabetic patients is occupying a front burner in the field of diabetology as the pharmacologic treatment for type 2 diabetes mellitus becomes more complex.,, Newer pharmacologic therapies and combinations of medications are increasingly becoming available with the aim of maintaining blood glucose to the recommended goal without provoking the risk of hypoglycemia. As a medical emergency, definition of hypoglycemia has been variable and different classification systems have been used in clinical practice, clinical trials, and pharmaceutical industries with variable qualitative , and quantitative definitions., Conceptually, hypoglycemia occurs when blood glucose drops to a level that is too low to sustain normal functioning that could result in harm while severe hypoglycemia is considered the blood glucose level at which the diabetes patient need help of another person to recover., It arises from abnormalities in the mechanism involved in glucose homeostasis and is characterized by reduction in plasma glucose concentration to a level that induces manifestations of neurogenic (adrenergic) and neuroglycopenic symptoms and signs with altered mental status and sympathetic nervous system stimulation.
Research studies on hypoglycemia have reported variable prevalence of hypoglycemia based on self-reported questionnaires, patients interview, medical records, and clinical trials among patients with diabetes on medications across different global population:,,,,,,, In a meta-analysis of published studies from 1998 and 2013 by Edridge et al., the prevalence of mild and moderate hypoglycemia was 45%, while severe hypoglycemia was 6%; in The United Kingdom Prospective Diabetes Study, 2.5% of newly diagnosed type 2 diabetic patients had hypoglycemic events per year while 0.55% experienced life-threatening hypoglycemia; in Turkey, 84.1% of the study participants experienced mild hypoglycemia, 60% moderate, and 15.5% severe hypoglycemia per year, and 41.37% was reported in OBSTACLE hypoglycemic study in Asia among type 2 diabetic patients on sulfonylureas. The occurrence of hypoglycemia events in patients with diabetes have also been reported in Nigeria  and other parts of the world such as South Africa, India, France, and among pilgrims on Haji, in Saudi Arabia.
Globally, researchers have documented that intensive glycemic control does not minimize all-cause mortality , rather it is rarely achieved safely without hypoglycemia. However, morbidity and mortality associated with hypoglycemia in patients with diabetes have been reported in biomedical literature to include hypoglycemia-associated autonomic failure and associated syndromes, cardiovascular complications, decline in cognition, decrease work productivity, reduced health-related quality of life,, and death., Hypoglycemic event is, therefore, one of the dreaded complications of diabetes treatment that constitutes barrier to medication adherence , and impact on diabetes patient well-being and functioning, instills fear of medication use,, and invariably affects satisfaction with diabetic care.
Although good glycemic control remains the desired goal for both patients with diabetes and their physicians, unintended symptomatic hypoglycemia is alarming to the patient and family members., However, potential risk factors and predictors of hypoglycemia have been documented to include duration of diabetic disease, older age, pharmacokinetic imperfections,, excessive physical activity, dietary factors like excessive dieting  and fasting for laboratory tests, alcohol use, and hypoglycemia unawareness.
Researchers have demonstrated that blood glucose control to the recommended targets remains the desired goal in diabetic management and is intensively achieved without the risk of hypoglycemia.,, In a meta-analysis of published studies, it was reported that intensive blood glucose control in type 2 diabetic patients can result in 17% reduction in nonfatal myocardial infarction and 15% reduction in coronary heart disease events. However, intensive and tighter glycemic control has been shown to increase the risk of hypoglycemia ,,, thus necessitating the call to do no harm to a diabetic patient. As the impetus for the prevention of adverse diabetes-related hypoglycemic end-points grows, emphasis should be focused on its epidemiological elaboration and description. In Nigeria Africa, little is published on the epidemiology of hypoglycemia among type 2 diabetic patients on treatment. Of great concern in the study area is that a large gap in knowledge exists between hypoglycemic and hyperglycemic emergencies among diabetes patients. Effective reduction of hypoglycemic crisis syndrome in diabetic Nigerians depends largely on the adequate understanding of its epidemiology. Knowledge of the epidemiology of hypoglycemia will provide an insight into its distribution and will enable clinicians explore the risk factors for patient-centered care and targeted proactive interventions. It is based on this premise that the authors were motivated to study the epidemiology of hypoglycemia among ambulatory type 2 diabetic Nigerians in a primary care clinic of a tertiary hospital situated in Eastern Nigeria with the opportunity to identify high-risk diabetic patients in primary care clinic of the hospital.
| Materials and Methods|| |
This was a clinic-based cross-sectional descriptive study that was carried out on 145 diabetic patients from July 2016 to October 2016 at the department of family medicine of a tertiary hospital in Eastern Nigeria.
The department of family medicine serves as a primary care clinic within the tertiary hospital setting of the Medical Centre. All adult patients excluding those who need emergency health-care services, pediatric patients, and antenatal women are first seen at the department of family medicine where diagnoses are made. Patients who need primary care are managed and followed up in the clinic while those who need other specialists care are referred to the respective core specialist clinics for further management. The clinic is run by consultant family physicians and postgraduate resident doctors in family medicine.
The inclusion criteria were adult diabetes patients aged ≥18 years who had been on treatment for diabetes mellitus for at least 1 month. The exclusion criteria were critically ill diabetes patients, treatment naïve-diabetes patients, and patients with gestational diabetes.
Sample size estimation was determined using the formula for estimating minimum sample size for descriptive studies  using the formula n = Z2pq/d2 and nf = n/1 + n/N where n = Desired sample size when population is >10,000; nf = Desired sample size when population is <10,000; Z = Standard normal deviate set at 1.96 which corresponds to 95% confidence limit; p = Authors assumed that 50% (0.50) of the participants would experience hypoglycemia at 95% confidence limit and 5% margin of error; d = Desired level of precision was set at 0.05. When studying population less than 10,000 using an estimated population size in a given year, the total number of adult diabetic patients who attended family medicine clinic in 2015 was 220. These 220 adult diabetes patients excluded diabetes patients referred to and being followed up in the diabetic clinic and other outpatient clinics of the medical center, diabetes patients on emergency, and inpatient admissions. This gave a sample estimate of 142 patients. However, selected sample of 145 adult diabetes patients was used in order to improve the precision of the study.
The eligible adult diabetes patients were consecutively recruited for the study based on the inclusion criteria until the sample size of 145 was achieved.
The instrument for data collection was developed by the researchers around the objectives of the study and to suit Nigerian environment through robust review of literature on previous studies on hypoglycemia.,,,,,,, The questionnaire comprised sections on sociodemographic variables, selected epidemiological variables such as place and time of occurrence, duration of diabetes, symptoms of hypoglycemia, and type of antidiabetic medications.
Operationally, adult patients were classified based on their age into young adults who were aged 18–59 years and elderly patients who were aged 60 years and more. The time of experience of the hypoglycemic event was divided into two: daytime was defined inclusively as the time from 6.00 am to 6.00 pm Nigerian time, while nighttime refers exclusively to the time from 6.00 pm to 6.00 am Nigerian time.
Commonly used antidiabetic medications in the ambulatory care and outpatient department of the hospital are categorized based on their site and mechanism of action into the following: exogenous insulin (humulin 70/30 is the most commonly used); insulin secretagogues (sulfonylurea-glibenclamide is the most commonly available and used, glinides-repaglinides are most commonly used); insulin sensitizers (biguanides-metformin is the most commonly available and used, thiazolidinediones (glitazones)-pioglitazone is rarely used); gliptins (DPP-4 inhibitors (sitagliptins and vildagliptins are uncommonly used due to costs); and various fixed-dose formulations of oral hypoglycemic agents. Incretin mimetics (GLP-1 analogs) and sodium-glucose cotransporter-2 (SGLT-2) inhibitors (gliflozins) are not available.
The ethical approval for the study was obtained from the Health Research Ethics Committee of Federal Medical Centre Umuahia (Queen Elizabeth Hospital), Nigeria, with reference number FMC/QEH/G.596/Vol. 10/206 dated July 9, 2016. Consent was also obtained from the patients included in the study.
The data generated were analyzed using software International Business Machines Corporation, Statistical Package for the Social Sciences (IBM SPSS) version 21, New York, USA. Categorical variables were described by frequencies and percentages. Bivariate analyses involving Chi-square test was used to test for the significance of associations between categorical variables. Logistic regression analyses were performed where appropriate. In all cases, P < 0.05 was considered statistically significant. Odds ratio (OR) which is an indicator of degree of association of experience of hypoglycemic events with a predictor variable was estimated at 95% confidence limit.
| Results|| |
The age of type 2 diabetic patients ranged from 32 to 78 years with the mean age of 44 ± 10.2 years. There were 59 (40.7%) males and 86 (59.3%) females with sex ratio of 1:1.5 [Table 1].
Of the 145 type 2 diabetic patients who participated in the study, 51 of them had experienced at least one episode of hypoglycemic event giving a prevalence of 35.2%. Ninety-four of type 2 diabetic patients did not experience hypoglycemic event [Table 2].
|Table 2: Prevalence of hypoglycemia event among type 2 diabetic patients|
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On the distribution of hypoglycemic events among the 51 participants who had hypoglycemia, 37 (72.5%) of the hypoglycemic events occurred outside the home environment; 28 (54.9%) occurred at home while 13 (25.5%) occurred both at home and outside environment; 42 (82.4%) of the hypoglycemic events occurred during the daytime (6 am–6 pm inclusive), 25 (49.0%) occurred both the night and daytime while 17 (33.3%) happened during the night [Table 3].
|Table 3: Distribution of hypoglycemia event among type 2 diabetic patients who experienced hypoglycemia by place and time of occurrence|
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Among the type 2 diabetic patients who had hypoglycemic event, the most common symptom was dizziness (76.5%). Other symptoms are shown in [Table 4].
|Table 4: Distribution of type 2 diabetic patients who experienced hypoglycemia based on the symptoms of hypoglycemia event|
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Bivariate analysis of the demographic variables as related to experience of the hypoglycemic event showed that elderly age (≥60 years) was statistically significant (χ2 = 7.81; P = 0.025), while other demographic variables were not statistically significant. Similarly, Chi-square analysis of the duration of diabetes and type of antidiabetic medications as related to experience of hypoglycemic event, respectively, demonstrated that duration of diabetes ≤1 year (χ2 = 5.50; P = 0.021) and use of insulin secretagogues alone (χ2 = 10.60; P =0.043) were statistically significant [Table 5].
|Table 5: Association between sociodemographic factors, duration of diabetes, type of antidiabetic medications, and hypoglycemia event|
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However, on logistic regression analysis of factors as related to experience of hypoglycemic events showed that age (≥60 years), male gender, duration of diabetes (≤1 year), and type of antidiabetic medications (insulin and insulin secretagogues) were statistically significant, while other factors were not statistically significant [Table 6]. The most significant predictor of experience of hypoglycemic event was the use of insulin and insulin secretagogues (OR = 3.15; confidence interval = 1.74–5.66; P = 0.002). Diabetic patients on insulin and insulin secretagogues were three times more likely to experience hypoglycemic event compared to type 2 diabetic patients who were insulin sensitizers.
|Table 6: Logistic regression analysis of factors associated with experience of hypoglycemic event among type 2 diabetic patients|
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| Discussion|| |
This study has demonstrated that 35.2% of the study participants experienced hypoglycemia. The prevalence of hypoglycemia in this study is lower than the prevalence of 45% reported in a systematic review of literature on the prevalence of hypoglycemia by Edridge et al., 55% reported among diabetes patients in the United States of America, 41.37% reported in OBSTACLE Hypoglycemia Study, 84.1% and 60.0% reported for mild and moderate hypoglycemia in Turkey, and 42% reported in South Africa. However, the result of this study is <2.5% and 0.55% reported in The United Kingdom Prospective Diabetes Study, for hypoglycemic events and life-threatening hypoglycemia, respectively. The variable prevalence of hypoglycemic events in this study and the referenced studies ,,,,, can be attributed to epidemiological characteristics of the study population such as demographic, and ethnic variations, method of reporting, and wide spectrum of therapeutic regimens use in the management of diabetes mellitus. Although neurogenic and neuroglycopenic symptoms of hypoglycemia differ from person to person and from time to time, it is important for every diabetes patient to recognize his or her own symptoms. Admittedly, mild hypoglycemia can be emotionally distressful to the patient with diabetes; moderate hypoglycemia can be frightening while severe hypoglycemia is a medical emergency that could result in disability and unnecessary death. Since the risk of hypoglycemic event outweighs the changes in the surrogate diabetic clinical end-points,, prevention of hypoglycemia should be one of the health-care concerns in addition to controlling the effects of hyperglycemia.,,, The findings of this study therefore brings to the fore, the issue of the clinicoepidemiological variables that predispose diabetes patients to hypoglycemia. It is therefore pertinent for clinicians to be aware of the subtleties in the occurrence of hypoglycemia in order to determine appropriate interventional measures. The knowledge of these variables is crucial and critical for optimal care of diabetes patients. The diabetic patients should be educated on warning symptoms of hypoglycemia and appropriate acute interventions at workplace and home environment, especially in a resource-poor environment where there are limited options for appropriate diabetic care.
Hypoglycemia occurred predominantly among the elderly age group when compared with their younger counterparts. This finding is in consonance with previous reports of higher frequency of hypoglycemia in the elderly diabetes patient population.,, The higher occurrence of hypoglycemia among the elderly patients on diabetic medications could be due to somatic organ homeostenosis, comorbidities such as renal compromise associated with old age, and polypharmacy involving the use of concomitant medications that predispose to the risk of hypoglycemia among the elderly diabetes patients with multimorbid health conditions.,, Of great interest in the study area is that elderly diabetic Nigerians are likely to have more formal and informal support system, especially family support in ensuring strict adherence to medications and diets when compared with the younger age group who are largely independent and economically active.,, The younger diabetes patients are more likely to have greater aggregates and clusters of lifestyle and other risk factors that predispose to hyperglycemia rather than hypoglycemia when compared to the elderly diabetes patients.,,, Clinicians should therefore be more tolerant of slight abnormalities of blood glucose in elderly diabetes patients and not deprive them of occasional sugar-containing snacks when symptoms of hypoglycemia are not evident. It is therefore vital for health professionals to be aware of glucose variation in the elderly in order to facilitate appropriate hypoglycemic-oriented diabetes education while re-enforcing glycemic control to the recommended goal without provoking hypoglycemic events.
This study has shown that higher proportion of male diabetes patients experienced hypoglycemic events. Although gender similarities and differences have been reported for type 2 diabetes mellitus , and hypoglycemia , in different parts of the world, male patients bear greater burden of hypoglycemia in this study. The higher occurrence of hypoglycemia among the male diabetes patients in this study could be due to sociobehavioral and family factors.,,, However, male diabetes patients in the study area are more likely to be engaged in sociobehavioral and lifestyle activities such as alcohol consumptions , and strenuous domestic and occupational-related physical activity , that could predispose to hypoglycemia, especially when adherence to antidiabetic medications and diets are strictly observed. The findings of this study, therefore, beckon for an urgent need for further research studies in order to understand the disparity in the gender-related hypoglycemic events among diabetic patients on medications.
Thirty-seven (72.5%) type 2 diabetic patients experienced symptoms of hypoglycemia outside home environment. The higher occurrence of hypoglycemia outside home environment in this study could be a reflection of the biosocial characteristics of the study participants who were likely to be outdoors during the episode of hypoglycemia and may be involved in sociooccupational activities of daily living or observance of fasting for religious rites or in preparation for fasting blood glucose determination during the day. Research studies have demonstrated the influence of physical activities,, fasting for religious rites  and fasting-evoked en-route hypoglycemia  on blood glucose among diabetes patients on treatment. Since hypoglycemic event predominantly occurred outside home environment, there is need for patient, family and significant others education on treatment for hypoglycemia.,, Diabetes patient in Nigeria like their counterparts in advance nations of the world should wear medical identification bracelet or necklace which will help in emergency response. This is one of the ways that type 2 diabetic Nigerians will benefit from prehospital treatment of hypoglycemic crisis syndrome as well as prevention of hypoglycemia-related premature and unnecessary death and disability.
Forty-two (82.4%) of the type 2 diabetic patients experienced symptoms of hypoglycemia during the daytime (6 am–6 pm inclusive). Biophysiologically, blood glucose varies throughout the day from time to time with diurnal and nocturnal hypoglycemia reported in biomedical literature.,, However, the pathophysiologic mechanism underlying hypoglycemia in diabetes involves a complex interplay of physiological and behavioral response to falling plasma glucose.,, Although hypoglycemia can occur on any time of the day, research study has reported preponderance of episodes of hypoglycemia during the daytime. The predominant occurrence of diurnal hypoglycemia in this study could be a reflection of the role of external factors in blood glucose control such as physical, instrumental, domestic, and occupational activities of daily living., More so, daytime is the period of maximum physical activities of daily living in the study area among other societal activities such as alcohol use among the diabetic Nigerians.,, In addition, research studies have shown that hypoglycemia unawareness predominantly occurs during sleep due to reduced response to sympathoadrenal stimulation associated with hypoglycemia ,, and that sleep causes impaired awareness of hypoglycemia due to blunting of counterregulatory catecholamine response to hypoglycemia. In order to reduce the impact of diurnal hypoglycemia among the diabetes patients, it is important to identify patients at high risk, predispositional factors that result in absolute or relative insulin excess as well as careful consideration when choosing antidiabetic medications, medication dosing and timing, pattern of food consumption, and degree of physical exercise. There is therefore a need to use antidiabetic medications in a more physiologic fashion to achieve euglycemia in patients with type 2 diabetes mellitus without provoking hypoglycemia.
Thirty (58.8%) type 2 diabetic patients who experienced hypoglycemic events had duration of diabetes less than a year. This could be a reflection of the overzealous effort to attain normal glycemic control with the use multiple medications among diabetes patients whose duration of diabetes was less than a year., Of great interest in the study area is the widespread erroneous belief that people living with diabetes mellitus should not consume dietary carbohydrates  and this erroneous disposition is more pronounced in recently diagnosed diabetic patients. This wrong belief predisposes the diabetic patients to hypoglycemic crisis syndrome especially when such patients adhered strictly and consistently to the prescribed anti-diabetic medications. This erroneous disposition is more pronounced in recently diagnosed diabetes patients which predispose them to hypoglycemic crisis syndrome, especially when such patients adhered strictly and consistently to the prescribed antidiabetic medications. More so, the finding of less frequency of hypoglycemia among diabetes patients on treatment for >1 year could be due to repetitive information on adherence to antidiabetic medications and lifestyle modifications., There is, therefore, the need for rational use of antidiabetic medications in addition to appropriate diabetic self-management and family dietary and lifestyle education, particularly for the newly treated diabetic patients. This is necessary because decision on medication administration and diet are made on daily basis by patients and members of their family.
The most common symptom of hypoglycemia was dizziness with 76.5% of the study participants experiencing dizziness as the first symptom. This is similar but varies in proportion to the most common symptom of hypoglycemia reported in India  where 81.4% of diabetes patients experienced hypoglycemia and in the United States of America  with reported most common symptom of hypoglycemia being dizziness which occurred among 22% of the patients. Although neurogenic and neuroglycopenic symptoms that characterize the pathophysiology of hypoglycemia vary from person to person and from time to time, not every diabetes patient with hypoglycemia has dizziness but their chances are higher. For as much as every diabetes patient reaction to hypoglycemia is different, it is important for diabetes patients to recognize their own symptoms. Early recognition of the warning symptoms of hypoglycemia in every individual patient with diabetes remains quintessential in its prompt and appropriate treatment. The finding of this study is a clarion call for patient-centered  evaluation for hypoglycemic event, especially at the critical period of the episode of alarm and alert symptoms of hypoglycemia.
This study has demonstrated the variabilities in the occurrence of hypoglycemia among diabetes patients on commonly used antidiabetic medications in Nigeria. Patients on insulin secretagogues were mostly affected compared to patients on insulin sensitizers and gliptins. The finding of this study is in tandem with reports from the United Kingdom Prospective Diabetes Study, France, India, and South Africa. According to the United Kingdom Prospective Diabetes Study, American Diabetes Association, India Hypoglycemia Study Group, and other studies,,, hypoglycemia is a consequence of excess insulin either absolute or relative to the available glucose substrate for maintaining glucose homeostasis due to pharmacokinetic imperfections among other lifestyle and comorbid medical conditions. More so, the magnitude of overzealous prescriptions of antidiabetic medications and widespread clinical inertia in using standard clinical practice guidelines for management of type 2 diabetes mellitus are better imagined than witnessed in Nigeria environment and will not be helpful in attainment of beneficial therapeutic outcome among diabetic Nigerians. The implication of the overzealous prescription of antidiabetic medication is that physicians may attribute inadequate blood glucose control to therapeutic failure due to drug therapy rather than problem with adherence to medication resulting in the decision of increasing the dose of antidiabetic medications, changing medication, or adding another antidiabetic medication without adequate patient counseling and education. Furthermore, hypoglycemic events among the study participants could also be due to self-medication involving the concurrent use of two or more insulin secretagogues, intercurrent use of insulin and insulin secretagogues, and other medications that reduce blood glucose usually purchased from patent medicine dealers and vendors. The findings of this study provide an additional evidence of the need for clinicians' continuing professional development, especially on the use of newer antidiabetic agents with lower risk of hypoglycemia ,, and diabetic patients self-management education. Blood glucose control should be individualized based on patient characteristics with some degree of safety. Prevention of hypoglycemia has the potential to improve psychosocial aspect of patients living with diabetes including enhanced quality of life, improved adherence with antidiabetic medications, and avoidance of long-term complications of hypoglycemia.
Hypoglycemic crisis syndrome is one of the leading causes of morbidity and mortality from diabetes-related acute complications in Nigeria. Achieving target glycemic goals while avoiding hypoglycemia is a major challenge in the management of patients living with diabetes mellitus. Although the awareness of diabetes mellitus is increasing in Nigeria, knowledge of the causes, symptoms of diabetes-related hypoglycemia, and response to hypoglycemic episode are inadequate. Since ambulatory care is one of the mainstay services in the chronic care of diabetes patients, primary care clinicians attending to diabetes patient should strive to make hypoglycemic event more visible to diabetes patients in the interest of implementing diabetes self-management education. This study therefore makes for proactive primary care driven diabetes management an important health-care challenge with significant patient-oriented goals. Self-monitoring of blood glucose by the patient or medical caregiver should be encouraged in order to detect asymptomatic and symptomatic episodes of hypoglycemia and better adapt antidiabetic medication and lifestyles.
The limitations of the study are those inherent in questionnaire-based study and relied on the accuracy of the recognition of symptoms of hypoglycemia by the respondents. However, there is possibility that the respondents could have misdiagnosed hypoglycemia. Blood glucose estimation was not done by the respondents and this limited the categorization of hypoglycemic event into mild, moderate, or severe.
| Conclusion|| |
The study has shown variable epidemiology of hypoglycemia. The incident occurred predominantly among the elderly, male gender, during daytime, outside home environment, duration of diabetes ≤1 year, and patients on insulin and insulin secretagogues. Interventional measures for hypoglycemia should consider relevant epidemiological factors that predispose to hypoglycemia. This will facilitate appropriate hypoglycemic-oriented diabetes education while re-enforcing glycemic control to the recommended goal without provoking hypoglycemic events.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Ginter E, Simko V. Global prevalence and future of diabetes mellitus. Adv Exp Med Biol 2012;771:35-41.
Williams SA, Pollack MF, Dibonaventura M. Effects of hypoglycemia on health-related quality of life, treatment satisfaction and healthcare resource utilization in patients with type 2 diabetes mellitus. Diabetes Res Clin Pract 2011;91:363-70.
Chinenye S, Uloko AE, Ogbera AO Ofoegbu EN, Fasanmade OA, Fasanmade AA, et al
. Profile of Nigerians with diabetes mellitus – Diabcare Nigeria study group (2008): Results of a multicenter study. Indian J Endocrinol Metab 2012;16:558-64.
Oputa RN, Chinenye S. Diabetes in Nigeria – A translational medicine approach. Afr J Diabetes Med 2015;23:7-10.
Pascal IG, Ofoedu JN, Uchenna NP, Nkwa AA, Uchamma GU. Blood glucose control and medication adherence among adult type 2 diabetic Nigerians attending A primary care clinic in under-resourced environment of eastern Nigeria. N Am J Med Sci 2012;4:310-5.
Iloh GU, Okafor GO, Amadi AN, Ebirim CI. A cross-sectional study of adherence to lifestyle modifications among ambulatory type 2 diabetic Nigerians in a resource-poor setting of a primary care clinic in Eastern Nigeria. Int J Trop Dis Health 2015;8:113-23.
Ogunmola OO, Oladosu YT. Patterns of medical causes of deaths in adult accident and emergency department of a tertiary health centre situated in a rural setting of a developing country. J Med Med Sci 2013;4:112-6.
Waugh N, Cummins E, Royle P, Clar C, Marien M, Richter B, et al.
Newer agents for blood glucose control in type 2 diabetes: Systematic review and economic evaluation. Health Technol Assess 2010;14:1-248.
Büyükkaya Besen D, Arda Sürücü H, Koşar C. Self-reported frequency, severity of, and awareness of hypoglycemia in type 2 diabetes patients in Turkey. PeerJ 2016;4:e2700.
Noh RM, Graveling AJ, Frier BM. Medically minimising the impact of hypoglycaemia in type 2 diabetes: A review. Expert Opin Pharmacother 2011;12:2161-75.
Seaquist ER, Anderson J, Childs B, Cryer P, Dagogo-Jack S, Fish L, et al.
Hypoglycemia and diabetes: A report of a workgroup of the American Diabetes Association and the Endocrine Society. Diabetes Care 2013;36:1384-95.
Edridge CL, Dunkley AJ, Bodicoat DH, Rose TC, Gray LJ, Davies MJ, et al.
Prevalence and incidence of hypoglycaemia in 532,542 people with type 2 diabetes on oral therapies and insulin: A Systematic review and meta-analysis of population based studies. PLoS One 2015;10:e0126427.
International Hypoglycaemia Study Group. Glucose concentrations of less than 3.0 mmol/L (54 mg/dL) should be reported in clinical trials: A Joint position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2017;40:155-7.
Cryer PE. Mechanisms of hypoglycemia-associated autonomic failure in diabetes. N Engl J Med 2013;369:362-72.
Wright AD, Cull CA, Macleod KM, Holman RR; UKPDS Group. Hypoglycemia in type 2 diabetic patients randomized to and maintained on monotherapy with diet, sulfonylurea, metformin, or insulin for 6 years from diagnosis: UKPDS73. J Diabetes Complications 2006;20:395-401.
Kalra S, Deepak MC, Narang P, Singh V, Uvaraj MG, Agrawal N, et al.
Usage pattern, glycemic improvement, hypoglycemia, and body mass index changes with sulfonylureas in real-life clinical practice: Results from OBSTACLE hypoglycemia study. Diabetes Technol Ther 2013;15:129-35.
Pillay DK, Ross AJ, Campbell L. A review of hypoglycaemia in a South African family practice setting. Afr J Prim Health Care Fam Med 2016;8:e1-6.
Shriraam V, Mahadevan S, Anitharani M, Jagadeesh NS, Kurup SB, Vidya TA, et al.
Knowledge of hypoglycemia and its associated factors among type 2 diabetes mellitus patients in a tertiary care hospital in South India. Indian J Endocrinol Metab 2015;19:378-82.
Vexiau P, Mavros P, Krishnarajah G, Lyu R, Yin D. Hypoglycaemia in patients with type 2 diabetes treated with a combination of metformin and sulphonylurea therapy in France. Diabetes Obes Metab 2008;10 Suppl 1:16-24.
Ahmad J, Pathan MF, Jaleel MA, Fathima FN, Raza SA, Khan AK, et al.
Diabetic emergencies including hypoglycemia during ramadan. Indian J Endocrinol Metab 2012;16:512-5.
Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK prospective diabetes study (UKPDS) group. Lancet 1998;352:837-53.
Cryer PE. Hypoglycemia in diabetes: Pathophysiological mechanisms and diurnal variation. Prog Brain Res 2006;153:361-5.
Zoungas S, Patel A, Chalmers J, de Galan BE, Li Q, Billot L, et al.
Severe hypoglycemia and risks of vascular events and death. N Engl J Med 2010;363:1410-8.
Feinkohl I, Aung PP, Keller M, Robertson CM, Morling JR, McLachlan S, et al.
Severe hypoglycemia and cognitive decline in older people with type 2 diabetes: The edinburgh type 2 diabetes study. Diabetes Care 2014;37:507-15.
Brod M, Christensen T, Thomsen TL, Bushnell DM. The impact of non-severe hypoglycemic events on work productivity and diabetes management. Value Health 2011;14:665-71.
Barendse S, Singh H, Frier BM, Speight J. The impact of hypoglycaemia on quality of life and related patient-reported outcomes in type 2 diabetes: A narrative review. Diabet Med 2012;29:293-302.
McCoy RG, Van Houten HK, Ziegenfuss JY, Shah ND, Wermers RA, Smith SA, et al.
Increased mortality of patients with diabetes reporting severe hypoglycemia. Diabetes Care 2012;35:1897-901.
Bonds DE, Miller ME, Bergenstal RM, Buse JB, Byington RP, Cutler JA, et al.
The association between symptomatic, severe hypoglycaemia and mortality in type 2 diabetes: Retrospective epidemiological analysis of the ACCORD study. BMJ 2010;340:b4909.
Alvarez Guisasola F, Tofé Povedano S, Krishnarajah G, Lyu R, Mavros P, Yin D, et al.
Hypoglycaemic symptoms, treatment satisfaction, adherence and their associations with glycaemic goal in patients with type 2 diabetes mellitus: Findings from the real-life effectiveness and care patterns of diabetes management (RECAP-DM) study. Diabetes Obes Metab 2008;10 Suppl 1:25-32.
Davis S, Alonso MD. Hypoglycemia as a barrier to glycemic control. J Diabetes Complications 2004;18:60-8.
Brod M, Pohlman B, Wolden M, Christensen T. Non-severe nocturnal hypoglycemic events: Experience and impacts on patient functioning and well-being. Qual Life Res 2013;22:997-1004.
Wild D, von Maltzahn R, Brohan E, Christensen T, Clauson P, Gonder-Frederick L, et al.
A critical review of the literature on fear of hypoglycemia in diabetes: Implications for diabetes management and patient education. Patient Educ Couns 2007;68:10-5.
Stargardt T, Gonder-Frederick L, Krobot KJ, Alexander CM. Fear of hypoglycaemia: Defining a minimum clinically important difference in patients with type 2 diabetes. Health Qual Life Outcomes 2009;7:91.
Walz L, Pettersson B, Rosenqvist U, Deleskog A, Journath G, Wändell P, et al.
Impact of symptomatic hypoglycemia on medication adherence, patient satisfaction with treatment, and glycemic control in patients with type 2 diabetes. Patient Prefer Adherence 2014;8:593-601.
King J, Overland J, Fisher M, White K. Severe hypoglycemia and the role of the significant other: Expert, sentry, and protector. Diabetes Educ 2015;41:698-705.
Donnelly LA, Morris AD, Frier BM, Ellis JD, Donnan PT, Durrant R, et al.
Frequency and predictors of hypoglycaemia in type 1 and insulin-treated type 2 diabetes: A population-based study. Diabet Med 2005;22:749-55.
Chelliah A, Burge MR. Hypoglycaemia in elderly patients with diabetes mellitus: Causes and strategies for prevention. Drugs Aging 2004;21:511-30.
Shrestha SS, Shakya R, Karmacharya BM, Thapa P. Medication adherence to oral hypoglycemic agents among type II diabetic patients and their clinical outcomes with special reference to fasting blood glucose and glycosylated hemoglobin levels. Kathmandu Univ Med J (KUMJ) 2013;11:226-32.
Eriksson JW, Bodegard J, Nathanson D, Thuresson M, Nyström T, Norhammar A, et al.
Sulphonylurea compared to DPP-4 inhibitors in combination with metformin carries increased risk of severe hypoglycemia, cardiovascular events, and all-cause mortality. Diabetes Res Clin Pract 2016;117:39-47.
McGregor VP, Greiwe JS, Banarer S, Cryer PE. Limited impact of vigorous exercise on defenses against hypoglycemia: Relevance to hypoglycemia-associated autonomic failure. Diabetes 2002;51:1485-92.
Miller CD, Phillips LS, Ziemer DC, Gallina DL, Cook CB, El-Kebbi IM, et al.
Hypoglycemia in patients with type 2 diabetes mellitus. Arch Intern Med 2001;161:1653-9.
Aldasouqi S, Gossain V, Hebdon M. Causes of fasting-evoked en-route hypoglycaemia: A case series study. Int J Clin Med 2013;3:7A.
Cryer PE, Davis SN, Shamoon H. Hypoglycemia in diabetes. Diabetes Care 2003;26:1902-12.
Smith CB, Choudhary P, Pernet A, Hopkins D, Amiel SA. Hypoglycemia unawareness is associated with reduced adherence to therapeutic decisions in patients with type 1 diabetes: Evidence from a clinical audit. Diabetes Care 2009;32:1196-8.
Ray KK, Seshasai SR, Wijesuriya S, Sivakumaran R, Nethercott S, Preiss D, et al.
Effect of intensive control of glucose on cardiovascular outcomes and death in patients with diabetes mellitus: A meta-analysis of randomised controlled trials. Lancet 2009;373:1765-72.
Phung OJ, Scholle JM, Talwar M, Coleman CI. Effect of noninsulin antidiabetic drugs added to metformin therapy on glycemic control, weight gain, and hypoglycemia in type 2 diabetes. JAMA 2010;303:1410-8.
Viswanathan M, Joshi SR, Bhansali A. Hypoglycemia in type 2 diabetes: Standpoint of an experts' committee (India hypoglycemia study group). Indian J Endocrinol Metab 2012;16:894-8.
Kelly L. Glycaemic control: Do no harm. S Afr Fam Pract 2012;54:6-7.
Araoye MO. Sample size determination. Research Methodology with Statistics for Health and Social Sciences. Ilorin Nathadex Publishers; 2004. p. 115-21.
Lassmann-Vague V. Hypoglycaemia in elderly diabetic patients. Diabetes Metab 2005;31 Spec No 2:5S53-7.
Kong AP, Chan JC. Hypoglycemia and comorbidities in type 2 diabetes. Curr Diab Rep 2015;15:80.
Iloh GU, Amadi AN, Ebirim CIC Type 2 diabetes mellitus in ambulatory adult Nigerians: Prevalence and associated family biosocial factors in a primary care clinic in Eastern Nigeria: A cross-sectional study. Br J Med Med Res 2015;9:1-12.
Epidemiology of severe hypoglycemia in the diabetes control and complications trial. The DCCT research group. Am J Med 1991;90:450-9.
Galassetti P, Mann S, Tate D, Neill RA, Costa F, Wasserman DH, et al.
Effects of antecedent prolonged exercise on subsequent counterregulatory responses to hypoglycemia. Am J Physiol Endocrinol Metab 2001;280:E908-17.
Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, et al.
Management of hyperglycaemia in type 2 diabetes: A patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2012;55:1577-96.
Monnier L, Wojtusciszyn A, Colette C, Owens D. The contribution of glucose variability to asymptomatic hypoglycemia in persons with type 2 diabetes. Diabetes Technol Ther 2011;13:813-8.
Jones TW, Porter P, Sherwin RS, Davis EA, O'Leary P, Frazer F, et al.
Decreased epinephrine responses to hypoglycemia during sleep. N Engl J Med 1998;338:1657-62.
Gautier JF, Monguillon P, Verier-Mine O, Valensi P, Fiquet B, Dejager S, et al.
Which oral antidiabetic drug to combine with metformin to minimize the risk of hypoglycemia when initiating basal insulin? A randomized controlled trial of a DPP4 inhibitor versus insulin secretagogues. Diabetes Res Clin Pract 2016;116:26-8.
Swinnen SG, Dain MP, Aronson R, Davies M, Gerstein HC, Pfeiffer AF, et al.
A 24-week, randomized, treat-to-target trial comparing initiation of insulin glargine once-daily with insulin detemir twice-daily in patients with type 2 diabetes inadequately controlled on oral glucose-lowering drugs. Diabetes Care 2010;33:1176-8.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]