The errors of medicine administration observed in our study also highlighted the reality of patient-induced hypoglycemic episodes. They invite health professionals to change their approach and find more appropriate interpersonal interactions to discuss face-to-face issues of pharmacotherapy with their patients.
We did not design our study to identify the most prevalent medicine classes or individual agents associated with IH-related hospital admissions. Insulins and insulin-releasing agents (secratogogue) such as sulfonylureas and glinides were found unsurprisingly. The use of long-acting sulfonylureas in older TDM2 patients and combined therapy (sulfonylurea + voriconazole) found in our study should have been avoided. This constitutes inappropriate medicine prescriptions.
The economic and clinical burden of hypoglycemia is now better recognized under our real-life setting conditions. It requires the implementation of quality improvement strategies in daily practices.
Recurrent severe hypoglycemia can lead to a fear of hypoglycemia, which in turn can reduce adherence to therapeutic decisions and increase the risk of morbidity and mortality. As advocated, French, European, and American recommendations no longer systematically favor intensified regimens. Stopping glinides and sulfonylureas in fragile patients should be considered. In these patients, antidiabetic agents of the incretinomimetic class may be an alternative that leads to a lower risk of hypoglycemia. Newer, long-acting insulins (insulin glargine 300 U/mL or insulin degludec) with regard to their more flat and prolonged kinetic profile (up to 36 hours) also offer the advantage of lower risk of hypoglycemia compared with older basal insulins (insulin glargine U100/mL, insulin detemir). In the recent study of Karamat et al., switching to insulin degludec from basal insulins was estimated to achieve substantial cost savings in their cohort of patients due to the reduction of severe hypoglycemic events. As the cost of IH events is considerable, using appropriate targeted patients, newer long-acting insulins could therefore lead to significant cost savings despite their higher acquisition cost.
The development of continuous glucose monitoring (CGM) systems displaying values in real time has been intensively promoted during recent years, leading to CGM systems with approximately the same precision as currently available blood glucose meters. Implementation of routine use of CGM systems could then have a substantial benefit, especially in patients with impaired hypoglycemia awareness. However, the profile of “responsive” patients who get the best outcome from CGM has yet to be determined.
It also appears essential to offer the patient a tailored therapeutic education focused on the prevention of hypoglycemia, its identification, and management. In our clinical study, 64% of T1DM and only 36% of T2DM patients had participated in therapeutic education sessions. In addition, clinical pharmacist interventions, carried out at hospital discharge, could enable patients to better understand their treatment and thus reduce IH. These pharmacist interventions should primarily target at-risk diabetic populations of hypoglycemia e.g., T1DM patients and frail older patients with T2DM. A recent systematic review and meta-analysis confirmed that pharmacist interventions improve glycemic control in T2DM patients compared with usual care.
Corticophobia is present both among parents of young AD patients and pharmacy staff. Education of pharmacy staff followed by targeted patient counseling, effectively reduced corticophobia both among staff and parents. Furthermore, pharmacy staff’s knowledge about AD and treatment increased and patients seemed to experience less severe symptoms.
In line with previous studies, the parents in our study had negative perceptions towards TCS use. The total TOPICOP score in our study was 42%, similar to the score of 44% in the study of Bos et al. Parents mainly expressed their worries about side effects and negative consequences of (long-term) TCS use. Capozza et al. described worries about side effects as one of the top reasons for parents to deviate from treatment advice given by the physician. These worries can influence adherence and proper use of TCS. Incorrect use of treatment may exacerbate AD symptoms or side effects, resulting in decreased quality of life. Motivating parents to use treatment is thus of importance. Informing parents or caregivers about correct use of treatment and providing them with up-to-date information about effectiveness and safety may be effective in improving perceptions towards medicines and thereby increasing adherence rates.
