This article is more than 5 years old. Information may no longer be current.
Insulin use more likely among older, sicker adults with type 2 diabetes
Older adults with type 2 diabetes and worse overall health status were more than twice as likely to use insulin therapy when compared with similar adults with good health status, yet clinicians were more likely to discontinue an insulin regimen for healthier patients during 4 years of follow-up, according to a database analysis published in JAMA Internal Medicine.
“The patients using insulin were more likely to be sicker, and that part you sort of expect, but then we followed everyone on insulin forward to see who got stopped,” Richard W. Grant, MD, MPH, a research scientist in the division of research at Kaiser Permanente Northern California, told Endocrine Today. “Guidelines from leading organizations suggest that, the sicker you are, the less benefit you derive from insulin and the more you are at risk for hypoglycemia. The real issue is that risk-benefit balance, which favors insulin for most of your life, starts to flip as you age, and there are not real strong data on how to decide how to treat.”
In a longitudinal study, Grant and colleagues analyzed electronic health record data from 21,531 adults with type 2 diabetes in the Kaiser Permanente Northern California Diabetes Registry, followed for up to 4 years starting at age 75 years (48.3% women; mean age, 75 years; mean follow-up, 3.7 years; mean diabetes duration, 9.4 years). Researchers assessed insulin treatment and glycemic response from 2009 to 2017, defining health status as good (fewer than two comorbid conditions or two comorbidities but physically active), intermediate (at least two comorbidities or more than two comorbidities plus no self-reported weekly exercise) or poor (having end-stage pulmonary, cardiac or renal disease; diagnosis of dementia; or metastatic cancer).
Primary outcome was insulin use prevalence at age 75 years and discontinuation among insulin users during the next 4 years (or 6 months before death if less than 4 years).
Within the cohort, 4,076 adults (18.9%) used insulin in the year before age 75 years (mean duration of insulin use, 5.5 years). At baseline, researchers classified 51.3% of individuals as having good health, 40.1% as having intermediate health and 8.6% as having poor health.
Insulin use was more prevalent among individuals with poor health (29.4%) and intermediate health (27.5%) vs. those with good health (10.5%; P < .01). Researchers found that individuals with poor health were more than twice as likely to use insulin when compared with adults with good health (adjusted RR = 2.03; 95% CI, 1.87-2.2).
Additionally, researchers found that 32.7% of insulin users discontinued insulin within 4 years of cohort entry and at least 6 months before death. Individuals with good health were the most likely to discontinue insulin use during follow-up (38.9%), followed by those with intermediate health (32.7%) and those with poor health (27.6%; P < .01). The likelihood of continued insulin use was higher among individuals with poor health (adjusted RR = 1.47; 95% CI, 1.27-1.67) and intermediate health (adjusted RR = 1.16; 95% CI, 1.05-1.3) compared with individuals with good health. However, clinicians were more likely to simplify a patient’s insulin regimen if a person was in poor health (10.9%) vs. intermediate health (7.8%) or good health (4.7%; P < .01). Results persisted in analyses restricted to patients with an HbA1c of less than 7%.
“The main finding was that, starting at age 75 and looking 4 years forward, it was the healthier people who were more likely to be stopped than the sicker people, which is the opposite of what the guidelines suggest,” Grant said. “If you have an older patient who is in poor health and using insulin, you should have a conversation with that patient. This is not a situation where there is an exact right or wrong. You need to know the patient’s values and preferences.”
Grant said a clinician should discuss with an older patient the risks and benefits of aggressive vs. nonaggressive treatment of type 2 diabetes, factoring in other medications, comorbidities and health-related quality of life.
“It all had to be sorted out, and it is not an easy conversation,” Grant said. “Older patients almost by definition have a lot of other things going on. When you have a 15-minute visit, it is so easy to keep things the same. It is an investment of time to sit down and say, ‘Let’s reassess this.’”
Grant noted that the study was not designed to assess patient outcomes that might be associated with insulin use or discontinuation. – by Regina Schaffer
For more information:
Richard W. Grant , MD, MPH, can be reached at Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA 94612; email: richard.w.grant@kp.org.
Disclosures: The authors report no relevant financial disclosures.
Perspective
Back to Top
Most diabetes treatment guidelines suggest individualizing glycemic targets in patients with diabetes based on factors such as comorbidities and life expectancy. Emerging data suggest that many older individuals with diabetes are actually overtreated. Insulin therapy is, by its nature, more complicated and associated with a risk for hypoglycemia and would be a logical target for treatment deintensification.
This important study is one of the first to examine treatment deintensification in older adults with type 2 diabetes. Unexpectedly, the results from practice do not align with treatment recommendations. It is possible that these results simply reflect the severity of disease in those with poorer health and possibly more limited treatment options. Further research needs to be conducted to understand treatment deintensification in older individuals with diabetes. Moreover, effort needs to be directed toward the dissemination and implementation of diabetes treatment guidelines, and these efforts need to more effectively engage primary care providers who manage most of these older individuals at higher risk for overtreatment.
Collapse
Weiner JZ, et al. JAMA Intern Med. 2019;doi:10.1001/jamainternmed.2019.3759.
Read more about