Insulin discontinuation among patients over 75 more common in healthier patients

1. In this large, longitudinal cohort study from the United States, patients with poor health status were more likely to continue insulin use compared with healthier patients.

Evidence Rating Level: 2 (Good)

Study Rundown: Type 2 Diabetes Mellitus (DM2) is one of the most common chronic illnesses in the world. Glycemic control has been shown to improve micro and macrovascular outcomes, however results take time. Optimal adjustment of management in those 75 or older, especially with multiple comorbidities, is unclear as they are often excluded from clinical trials. Recommendations are to have looser glycemic control with older age and more comorbidities because of consequences of hypoglycemia.  This longitudinal study found that insulin continuation in those 75 or older was linked with poorer health status, wherein those with more comorbidities were more likely to continue insulin use.

Limitations of this study included an oversimplified stratification of health status, inability to capture differences in insulin dosing (which means only total cessation was captured, rather than potential dose reductions), as well as inability to confirm if the cessation was driven by clinician recommendation or patient choice. Overall, further study is warranted to evaluate if older, more frail patients who are more susceptible to hypoglycemia are having insulin dosing appropriately lowered or stopped.

Click to read the study in JAMA Internal Medicine

Relevant Reading: Intensive Blood Glucose Control and Vascular Outcomes in Patients with Type 2 Diabetes

In-Depth [prospective cohort]: This was a longitudinal cohort study of patients 75 and older with type 2 diabetes mellitus (DM2). The baseline cohort included those who used insulin at enrollment (n=21 531, baseline cohort of 4076). The primary outcome was insulin discontinuation in the next 4 years. Data was collected from 2009 to 2017. Patients were stratified into poor (any indicator of end stage disease including home oxygen use, metastatic cancer, Stage V CKD, dialysis, or dementia), intermediate (2 comorbidities and no weekly exercise, >2 comorbidities, or use of a walker), and good health (<2 comorbidities or 2 comorbidities with any weekly exercise).

There were 1,335 patients (32.7% of baseline cohort) who discontinued insulin within 4 years. Insulin discontinuation was highest in the cohort with good health (38.9% vs 32.7% intermediate health vs 27.6% poor health). Adjusted risk ratio for insulin continuation for those with poor health was 1.47, 95% CI 1.27-1.67, p<0.01) compared to those with good health.

Image: PD

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