For Clinicians - Quality, Safety & Value
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Quality, Safety & Value


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For Clinicians

The VHA Choosing Wisely Hypoglycemia Safety Initiative (CW-HSI) considers many different aspects of diabetes treatment as well as hypoglycemia risk and recommendations regarding managing that risk, some of which are briefly described below. For detailed CW-HSI information, please visit the Clinicians’ Resources, FAQs for Clinicians, and Available Literature pages linked on the left. This focus on hypoglycemia is not specific to the VA: a Federal Interagency Workgroup, led by Drs. Clydette Powell (HHS/OASH/ODPHP), Leonard Pogach (VHA), and Christine Lee (FDA), has been created that includes members from multiple federal agencies with the common goal of improved diabetes management and reducing the risk of hypoglycemia.

Hypoglycemia risk is multi-factorial: Intensive management of diabetes increases the risk of hypoglycemia.1,2 Hospitalization rates for hypoglycemia were higher for older patients (≥75 years) among Medicare beneficiaries 65 years or older from 1999 to 2011 and these rates now exceed those for hyperglycemia among older adults.3 Cognitive impairment also increases the risk of hypoglycemia.4 Insulins (13.9%) and oral hypoglycemics (10.7%) were among the top 4 drug classes implicated in emergency department visits and hospitalizations.5 

Within the Choosing Wisely Initiative, the American Geriatrics Society recommends to “Avoid using medications to achieve A1C <7.5% in most adults age 65 and older; moderate control is generally better.”6

Overtreatment of elderly Veterans with diabetes is common with 38% of Veterans >65 years of age having an A1C <7% and 7.5% having hypoglycemia documented in past two years. Among Veterans with dementia, 14% had hypoglycemia documented in past two years.4

Patients at greatest risk for hypoglycemia include those with A1C <6% (4x risk), <6.5% (2.25x risk), or <7.0 (2x risk); treatment with insulin (5x risk) or a sulfonylurea (2x risk); age >75; and/or cognitive impairment or dementia.7

Hypoglycemia, even if mild, has significant consequences
including lower health-related quality of life, higher mortality, increased risk for cardiovascular disease, serious fractures related to falls, and automobile crashes.8,9,10


  • Review patients at greatest risk for hypoglycemia
  • Identify an individualized A1C goal based on patient preferences, complications, and co-morbidities
  • Reduce or eliminate unwarranted medications, focusing on insulins or sulfonylureas first as they pose the greatest risk for hypoglycemia
  • In general, the goal is to relax the A1C target when appropriate based on evidence and safety. Preference is to evaluate A1C target before considering adding alternative agents.


1. Patel A, McMahon S, Chalmers J, et al: Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008; 358:2560-72.

2. Bonds DE, Miller ME, Bergenstal RM, et al: The association between symptomatic, severe hypoglycemia and mortality in type 2 diabetes: Retrospective epidemiological analysis of the ACCORD study. BMJ 2010; 340:b3409.

3. Lipska KJ, Ross JS, Wang Y, et al: National trends in US hospital admissions for hyperglycemia and hypoglycemia among Medicare beneficiaries, 1999 to 2011. JAMA Intern Med 2014;174(7):1116-24.

4. Feil DG, Rajan M, Soroka O, et al: Risk of hypoglycemia in older Veterans with dementia and cognitive impairment: Implications for practice and policy. J Am Geriatr Soc 2011;59(12):2263-72.

5. Budnitz DS, Lovegrove MC, Shehab N, et al: Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med 2011: 365: 2002-12.


7. Tseng CL,Soroka O, Maney M, et al: Assessing potential glycemic overtreatment in persons at hypoglycemic risk. JAMA Intern Med 2014: 174(2):259-68.

8. Green AJ, Fox KM, Grandy S; SHIELD Study Group. Self-reported hypoglycemia and impact on quality of life and depression among adults with type 2 diabetes mellitus. Diabetes Res Clin Pract 2012;96(3):313-8.

9. Johnston SS, Conner C, Aagren M, et al. Association between hypoglycaemic events and fall-related fractures in Medicare-covered patients with type 2 diabetes. Diabetes Obes Metab 2012;14(7):634-43.

10. Pedersen-Bjergaard U, Færch L, Allingbjerg ML, et al. The influence of new European Union driver's license legislation on reporting of severe hypoglycemia by patients with type 1 diabetes. Diabetes Care 2015;38(1):29-33.