The recent publication in Diabetes Care by Christiaens et al. (1) represents an innovative approach by using HbA1c to assess hypoglycemia risk in elderly individuals with type 2 diabetes. The authors examined both fixed and individualized proxy definitions of overtreatment, revealing that neither approach demonstrated a strong correlation with hypoglycemic events. This finding underscores the inherent challenges of predicting hypoglycemia in this demographic and highlights the need for more nuanced clinical methodologies. Despite these limitations, the study provides foundational insights that hold significant implications for optimizing therapeutic strategies in this vulnerable population. Below, we elaborate on the study’s contributions while addressing critical areas that merit further exploration.
A key limitation of the study is the omission of a detailed analysis of insulin regimens and their association with time below range (TBR). Could the authors provide data on insulin types, dosages, and the concurrent use of other glucose-lowering agents to better understand their impact on hypoglycemia risk? Given the well-documented relationship between insulin therapies and hypoglycemia risk (2), providing a more granular analysis of these regimens could significantly enhance the study’s insights.
The use of continuous glucose monitoring (CGM) systems provides an exceptional method for tracking glycemic trends, yet it presents notable challenges in elderly populations (3). Current guidelines for the general diabetes population suggest maintaining TBR below 4% for glucose levels under 70 mg/dL and below 1% for levels under 54 mg/dL. However, the American Diabetes Association 2025 guidelines specifically recommend that for older adults, the time spent with glucose levels below 70 mg/dL should not exceed 1% (approximately 15 min per day) to minimize hypoglycemia risk (4). The study’s primary outcome focused on achieving a TBR <1% for glucose levels under 70 mg/dL. While this stringent target aligns with established guidelines for older adults aimed at reducing hypoglycemia, it raises questions about the feasibility of maintaining such low TBR thresholds in real-world settings, especially among elderly populations who may face challenges such as fluctuating daily routines, varying insulin sensitivities, and potential barriers to consistent CGM use.
Balancing tight glycemic targets with the practical challenges faced by elderly patients is crucial for optimizing diabetes management. To address this, the authors could provide a sensitivity analysis exploring TBR <4% for level 1 hypoglycemia and TBR <1% for level 2 hypoglycemia. Such an analysis would offer insights into the practicality of these targets and their impact on clinical outcomes, ensuring that glycemic control strategies are both effective and achievable in diverse patient populations. Although the current end point offers valuable insights into precision glycemic management, it risks overshadowing broader and equally critical aspects of diabetes care in this population.
The omission of dietary influences during the monitoring period represents a notable gap in the study. While clinical evidence underscores the significant role of dietary modifications, such as carbohydrate regulation and diabetes-specific meal planning (5), the authors did not provide detailed dietary information for participants. Additionally, although baseline medication data were presented, the study did not examine the correlation between specific medications and hypoglycemic events. Including detailed dietary information could enhance the interpretive depth regarding hypoglycemia risk. Exploring these relationships would provide a more comprehensive understanding of how therapeutic strategies influence glycemic outcomes. To enhance the study’s robustness, it would be beneficial for the authors to provide additional data on insulin regimens, dietary influences, and specific medication correlations with hypoglycemic events. Furthermore, future research should explore the integration of detailed therapeutic strategies and lifestyle factors to develop more comprehensive predictive models for hypoglycemia risk in elderly populations with diabetes. Such advancements could significantly improve personalized diabetes care and patient outcomes.
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Duality of Interest. No potential conflicts of interest relevant to this article were reported.
Handling Editors. The journal editors responsible for overseeing the review of the manuscript were Steven E. Kahn and Vanita R. Aroda.
