A Rational Approach to the Initiation of Insulin Therapy in Older Adults

Mae Sheikh-Ali, MD; Joe M. Chehade, MD

Disclosures

Geriatrics and Aging. 2009;12(3):135-140. 

In This Article

Abstract and Introduction

Abstract

Over the past decade, eight classes of drugs have been used to treat diabetes; however, insulin remains the most effective and least costly treatment for older adults. The American Diabetes Association has recommended that the approach to drug therapy of diabetes consider insulin a first-tier therapy. Nevertheless, there is a general reluctance among physicians and patients alike to accept insulin. The initiation of insulin therapy is especially challenging in older adults, who often have multiple comorbidities and physical limitations. In this article, we present a case-based approach to the initiation of insulin therapy in older adults.

Introduction

Diabetes is a very common condition among older adults.[1,2] It is estimated that one in every five people 65 years of age and older have diabetes, and the prevalence of diabetes among older adults is expected to increase by 44% in the next 20 years.[3] Older adults newly diagnosed with diabetes experience high rates of complications during the subsequent 10 years, far in excess of those in older people without this diagnosis.[4]

Over the past decade, eight classes of drugs have been used to treat diabetes: sulphonylureas, biguanides, alpha-glucosidase inhibitors, meglitinides, thiazolidinediones, exenatide, dipeptidyl peptidase IV inhibitors, and pramlintide. However, insulin remains the most effective and least costly treatment for older adults.[5] The advent of novel insulin analogues has improved the safety and convenience of insulin therapy.[6] However; there is still some controversies on the superiority of insulin analogues over humulin insulin in terms of cost/benefit profile. The American Diabetes Association has recommended that the approach to drug therapy of diabetes consider insulin a first-tier therapy.[7] Insulin has no upper dose limit and, unlike other antidiabetic agents, it has no contraindications to its use.[8] Nevertheless, there is a general reluctance among physicians and patients alike to accept insulin. The fear of injections, the need for multiple daily glucose tests, and the perceived risks of hypoglycemia have been major deterrents to the widespread acceptance of insulin as first-line therapy (Figure 1). The initiation of insulin therapy is especially challenging in older adults, who often have multiple comorbidities and physical limitations.

Figure 1.

An Overview of Insulin

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