Defying guidelines, Insulin use high in older diabetes patients with poor health: JAMA

USA: Current diabetes guidelines recommend reducing treatment intensity of insulin as health status declines in older patients. Despite this, insulin use is being increased in older patients who are in poor health, finds a recent study published in the JAMA Internal Medicine journal.

According to the study, in older adults with type 2 diabetes, insulin use was found to be prevalent in those with poor health wheres insulin was discontinued in healthier patients after 75 years of age.

The results suggest a need to better align current practice with guidelines that support reducing treatment intensity as health status declines.

Persistent insulin use among older adults with poor health increases the risk of hypoglycemia (low blood sugar) and has limited health benefit in the future.

Jonathan Z. Weiner, Division of Research, Kaiser Permanente of Northern California, Oakland, and colleagues examined whether insulin treatment is used less frequently and discontinued more often among older individuals with poor health compared with those in good health.

For the purpose, the researchers designed a longitudinal cohort study using data from the Kaiser Permanente Northern California Diabetes Registry. The participants in the current study turned 75 between 2009-2013.

Investigators analyzed participants clinical characteristics for 2 years prior to turning 75 years old and all participants in the study were followed for up to 4 years. Individuals using insulin at 75 years of age were compared based on whether or not they discontinued insulin use during the 4-year follow-up period.

A total of 21,531 patients were identified for inclusion, of which 4076 (18.9%) used insulin. In regard to the study cohort, 10,396 (48.3%) were women, the mean diabetes duration was 9.4 years, and mean follow-up time was 3.7 years. Investigators classified 11,041 (51.3%) as having good health, 8632 (40.1%) as having intermediate health, and 1858 (8.6%) as having poor health.

Key findings include:

• Nearly one-fifth of 75-year-olds (4076 [18.9%]) used insulin.


• Prevalence and adjusted risk ratios (aRRs) of insulin use at age 75 years were higher in individuals with poor health (29.4%) and intermediate health (27.5%) relative to good health (10.5% [reference]).


• One-third (1335 of 4076 [32.7%]) of insulin users at age 75 years discontinued insulin within 4 years of cohort entry (and at least 6 months prior to death).


• Likelihood of continued insulin use was higher among individuals in poor health (aRR, 1.47) and intermediate health (aRR, 1.16) compared with good health (reference).


• This same prevalence and discontinuation patterns were present in the subset with tight glycemic control (hemoglobin A_1c <7.0%).

"As patients with type 2 diabetes continue to age, there arises a need for evidence-based treatment strategies specifically related to insulin use in these older patients," wrote the authors.

"We found that the older adults in poorest health were most likely to use insulin and that subsequent insulin discontinuation was most common among healthier individuals. The substantial and persistent insulin use among older adults with a high risk of hypoglycemia and limited future benefit suggests that more work is needed to develop systems-based approaches that support guideline-concordant insulin use in people older than 75 years," they concluded.

To read the complete study follow the link: 10.1001/jamainternmed.2019.3759