Sick Elderly With Diabetes Stay on Insulin -- Is This a Surprise?

Miriam E. Tucker

September 27, 2019

Among adults with type 2 diabetes older than 75 years, those in poorer health were more likely to use insulin whereas those in better health were less likely to continue using it, a new large health plan database study has found.

The results, from more than 20,000 individuals aged 75-79 years, were published online September 23 in JAMA Internal Medicine by Jonathan Z. Weiner, MD, MPH, of the Division of Research, Kaiser Permanente of Northern California, Oakland, and colleagues.

The study findings are contrary to the authors' hypothesis that adults with poor health would be more likely to discontinue insulin after age 75 years.

"The observed pattern of insulin discontinuation in the present study runs contrary to what we would expect to find based on [American Diabetes Association] and other guideline recommendations that suggest relaxed glycemic control in adults with poor health status," Weiner and colleagues write.

But one expert on treating the elderly with diabetes tells Medscape Medical News that the findings aren't necessarily a surprise. 

Little Guidance on Treatment, None on Insulin Use, in Older Patients

Despite the fact that type 2 diabetes affects more than 20% of people over the age of 75 years in the United States, there is little evidence to guide treatment in that age group as they are usually excluded from clinical trials, Weiner and colleagues point out.  

And any benefits of tight glycemic control may not appear during the remaining lifespans of such individuals and their risk of hypoglycemia is greater than in younger people.

Professional societies advise higher glycemic targets for older adults on an individualized basis, but none specifically address the use of insulin, the authors note.

"Existing...guidelines provide frameworks for prescribers to contemplate deintensification but do not necessarily provide practical recommendations to implement this process into everyday practice...More trials are needed to provide clinicians with practical tools and protocols to reduce the use of high-risk, low-benefit medications," they write.

Simplification of Therapy Can Still Mean Insulin Use

The findings of the new trial make sense to one expert, however.

"I'm not surprised that people in poor health are on insulin because they often don't have other options," said Medha N. Munshi, MD, director of Joslin Geriatric Diabetes Programs at Beth Israel Deaconess Medical Center, and associate professor of medicine at Harvard Medical School, Boston, Massachusetts.

Other oral glucose-lowering medications are often contraindicated in such patients, for example because of renal insufficiency, she explained.

Moreover, Munshi, who was a coauthor of the 2012 ADA consensus report on diabetes in the elderly and a 2016 ADA statement on diabetes care in residential facilities, noted that the goal for older adults with type 2 diabetes isn't "de-prescribing" of insulin per se, but to make sure the treatment regimen aligns with patients' needs and goals, which change as they age.

"We should be focusing on making sure the complexity fits the patient. Simplification could still include insulin, and in some cases, there aren't other options," said Munshi. 

She also lamented that current guidelines are based largely on expert opinion because of the lack of data in older adults.

"We have to stop that and start doing studies focused on aging and diabetes, and not just epidemiological and observational studies and subpopulation analyses," she said.

Those in Poorer Health Most Likely to Continue Insulin

The study by Weiner and colleagues included 21,531 individuals older than 75 years with type 2 diabetes for a mean duration of 9.4 years.

At baseline, 51.3% were classified as having good health, defined as less than two comorbidities or two comorbidities yet still with evidence of physical activity. Another 40.1% had intermediate health, defined as more than two comorbidities or two comorbidities without evidence of physical activity. The other 8.6% had poor health, defined as having any end-stage disease regardless of the number of comorbidities.

Overall, 18.9% used insulin in the year prior to turning 75 years old, with a mean 7.9 years' duration of use. The proportions using insulin among those in poor, intermediate, and good health were 29.4%, 27.5%, and 10.5%, respectively (P < .01).

Compared to those with good health, adjusted risk ratios for insulin use were 1.85 for intermediate health and 2.03 for poor health (both P < .01). 

Over a mean follow-up of 3.7 years, 32.7% of the overall group who were using insulin at age 75 years discontinued using it, at a mean of 1.6 years, while insulin regimens were simplified in 7.9%.

Insulin discontinuation was significantly more likely among patients with a last measured hemoglobin A1c of 7.0% or less.

The proportions of patients who discontinued insulin among those with good, intermediate, and poor health were 38.9%, 32.7%, and 27.6%, respectively (P < .01).

However, the opposite pattern was seen with insulin continuation, which occurred in 4.7%, 7.8%, and 10.9%, respectively (P < .01).

Compared with good health, adjusted risk ratios for continued insulin use were 1.47 for poor health and 1.16 for intermediate health (both P < .01).

More Study Needed to See if Insulin Continuation Appropriate or Not

According to Weiner and colleagues, "The results of this study suggest that neither prevalent insulin use nor subsequent insulin discontinuation among older patients is closely aligned with current recommendations to incorporate health status (in conjunction with life expectancy and patient preferences) when making treatment decisions."

But Munshi cautioned, "The findings should not be interpreted as saying patients need to be taken off treatment...More focused studies need to be done to say whether it's appropriate or not."

Earlier this week, Munshi led a 2-day meeting of about 30 experts interested in diabetes and aging. Among the topics discussed were the available evidence to guide decision-making in older adults with diabetes, the current knowledge gaps, and both short- and long-term solutions. A white paper is planned.

Internal funding for the study was awarded by Kaiser Permanente of Northern California. Weiner has also reported receiving support from the Division of Research Delivery Science Fellowship Program. Munshi has reported being a consultant for Sanofi and Eli Lilly.

JAMA Int Med. Published online September 23, 2019. Abstract

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