Type 2 diabetes

Insulin overtreatment still occurring in elderly patients

Insulin therapy is not being relaxed or discontinued in elderly people with type 2 diabetes, contrary to recommendations that treatment should reflect the changing risk-to-benefit ratio with life expectancy and health status.

A US cohort study that followed 21,531 adults over 75 for 4 years found that discontinuation of insulin treatment was more common in healthier patients.

Overall, 18.9% of the study group used insulin in the year prior to turning 75. One-third of patients (32.7%) using insulin at age 75 years discontinued insulin during the 4-year follow-up period, and insulin regimens were simplified in only 7.9% of patients.

“Insulin discontinuation was significantly more prevalent among patients with a last measured HbA1c 7.0% or less,” the study found.

Insulin discontinuation was greatest among patients with good health (38.9%), followed by intermediate health (32.7%), and poor health (27.6%).

“By contrast, insulin regimen simplification was most common among those with poor health (99 of 909 [10.9%] vs 185 of 2380 [7.8%] for intermediate health and 37 of 787 [4.7%] for good health; P<.01),” the study said.

“Diabetes duration less than 10 years, HbA1c less than 7.0%, and use of long-acting insulin (reference, combination) were independently associated with insulin discontinuation.”

“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.”

“For example, we would expect to find less insulin discontinuation among relatively healthy patients with poor glycemic control (HbA1c ≥8.5%) relative to less healthy patients because these healthier patients are more likely to realize long-term clinical benefit with the tighter control that would be expected from continuing insulin therapy.”

“The observed pattern of insulin discontinuation in the present study runs contrary to what we would expect to find based on ADA and other guideline recommendations that suggest relaxed glycemic control in adults with poor health status.”

Commenting on the study on behalf of the ADS, Associate Professor Sof Andrikopoulos told the limbic continuing insulin use among older adults was trading off any diminishing benefit in terms of preventing complications versus the increasing risks of hypoglycaemia, falls and deterioration of quality of life.

“The ADS position is, and I think the article brings this out, that you need to individualise care. So you can have an 80 year-old who is relatively healthy and requires more aggressive glycaemic control versus a 60 year-old with multiple comorbidities or close to end stage renal disease in whom you would back off on managing their blood glucose levels.”

“The other position of the ADS is that in elderly people with a shorter duration of life expectancy, long duration of disease, with increased risk of hypoglycaemia then a high target HbA1c is probably reasonable.”

He said any HbA1c above 7.5%, 8% or even 8.5% was reasonable for an older person with multiple comorbidities and an increased risk of hypoglycaemia or hypoglycaemia unawareness.

“But again that comes down to the individual and their health professional to set that target.”

Associate Professor Andrikopoulos said the older person has to be managed according to individual factors such as their socioeconomic and cognitive status.

“I think it comes down to quality of life when dealing with an elderly population. Maybe they are not at home, maybe they are alone and don’t have a partner to look after them – all these issues need to be looked at holistically as well as managing their diabetes and their comorbidities.”

Ensuring that the adverse effects of insulin in an ageing population are being managed by titrating down or discontinuing insulin is a good thing, he said.

“Again, it comes down to the individual – how engaged they are with their health, how mentally aware they are, are they able to say yes they can take more or less insulin and manage that?”

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