2025 Southeastern Residency Conference

Title: Reducing the Risk of Hypoglycemic Events through Targeted Interventions Focused on Veterans at High Risk 


Authors:  Jessica Richardson, Blair Andreassi, Tiffany Jagel, Katrina White


Objective: Identify Veterans at high risk for hypoglycemia and evaluate the diabetes medications prescribed, focusing on medications with high hypoglycemic risk. 


Background: Hypoglycemia is a significant risk for older adults with diabetes, particularly those receiving insulin or sulfonylureas. Current guidelines from the American Diabetes Association (ADA), American Geriatrics Society (AGS), and Endocrine Society emphasize individualized glycemic targets, recommending an A1C goal of 7-8% (or higher in frail individuals) rather than intensive glucose control. Studies, including the ACCORD, ADVANCE, and VADT trials, have demonstrated that stringent glycemic control in older adults does not significantly reduce macrovascular complications but increases the risk of hypoglycemia-related harm, such as falls. The 2014 Choosing Wisely Hypoglycemic Safety Initiative (CW-HSI), which was used to identify high risk Veterans, was created to reduce the risk of hypoglycemia and to ensure Veterans have a personalized plan for blood sugar control based on their unique health goals.


Methods:This was a multi-center, prospective quality improvement project conducted within the Gulf Coast Veterans Health Care System. The CW-HSI dashboard was used to identify Veterans 65 years and older within the Gulf Coast Veterans Health Care System with a diagnosis of type 2 diabetes, a glycated hemoglobin of <6%, and prescribed a sulfonylurea and/or insulin. Veterans with type 1 diabetes and/or those who had not been seen by Veterans Affairs primary care within the past 3 years were excluded. After identification of Veteran from the dashboard, the Veteran was contacted by the pharmacist to discuss findings. During the appointment, the pharmacist focus was placed on diabetes management including medication adherence, blood glucose readings, recent hypoglycemic events, and education on the treatment of hypoglycemic events. After collection of information from the Veteran, medication modifications such as discontinuation or dose reduction was implemented. After initial appointment with pharmacist, if Veteran was deemed as needing further interventions Veteran was followed up by clinical pharmacist practitioner.  Otherwise, Veteran was followed up by their provider care clinician. Documentation of medication interventions, such as dosing modification, discontinuation, and prescribing of medications for treatment of hypoglycemic events were tracked via excel sheet to evaluate the impact of this project. The primary endpoint of the project was the frequency of medication interventions. Secondary endpoint was the number of hypoglycemic prevention medications prescribed.  All data was analyzed using descriptive statistics.


Results: A total of 112 patients meeting the inclusion criteria were identified from the CW-HSI dashboard. Of these, 41 patients were excluded due to ongoing medication modifications and elevated A1C levels, 14 patients were deceased prior to contact, and 2 patients could not be reached after multiple attempts, resulting in 55 patients being contacted. Among those contacted, 95% (52 patients) agreed to implement medication modifications. The primary interventions were the discontinuation of sulfonylureas in 22 patients (42%) and a reduction in the insulin regimen in 20 patients (38%). Additional modifications included a dose reduction of sulfonylureas in 9 patients (17%) and complete discontinuation of insulin in 1 patient (5%). Furthermore, 16 patients were prescribed a hypoglycemic treatment agent.


Conclusion: Pharmacist-led deprescribing was effective in reducing the number of Veterans on diabetes medications that are high risk hypoglycemic events, thus reducing risk hypoglycemic events.