Answer 1 is incorrect. 7.42% chose this answer. “LM has chronic kidney disease, and we note he is taking an ACE and SGLT-2.”  Answer 1 is somewhat true but is not the best answer. We may consider this question incorrect due to the statement that LM is taking ACE and SGLT-2 medications, and we know these have a low risk of hypoglycemia. However, a diagnosis of CKD, especially along with basal insulin therapy, can be a factor that increases hypoglycemia risk. If LM’s GFR was below 15 with a diagnosis of end-stage renal disease, then we would consider this a major risk factor. Let’s keep reading for the best answer. 

Answer 2 is incorrect. 8.36% of you chose this answer. “Basal insulin therapy alone.” Answer 2 is also true but is not the best answer. Hypoglycemia risk is highest in individuals treated with intensive insulin therapy followed by basal insulin and then sulfonylureas.1 Basal insulin therapy is a risk factor for hypoglycemia, and we may be tempted to select this answer alone. However, other considerations also impact LM’s risk for hypoglycemic events while on basal insulin therapy.

Answer 3 is incorrect. About 15.26% of respondents chose this. “Income status.” Answer 3 is also true but is not the best answer. Income status and food insecurity are considered risk factors for hypoglycemia and are associated with increased hospital admissions and ER visits. However, we must also consider this along with medication treatment. Food insecurity along with LM’s basal insulin therapy is a major risk factor for hypoglycemia.  

Finally, Answer 4 is correct. 68.97% chose this answer. “All the above.” Answer D is the correct Answer. The 2024 Standards of Care recommends hypoglycemia assessment at every clinical visit. We can use validated tools to determine risk for hospital admission or an ER visit, but these do not consider every risk factor. It is important to consider not only clinical factors but also social, economic, and cultural factors. Risk stratification is for all individuals treated with insulin, sulfonylureas, or meglitinides. ­° American Diabetes Association Professional Practice Committee; 6. Glycemic Goals and Hypoglycemia: Standards of Care in Diabetes—2024. Diabetes Care 1 January 2024; 47 (Supplement_1): S111–S125. https://doi.org/10.2337/dc24-S006

We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!