September 23, 2019
By Megan Brooks
NEW YORK (Reuters Health) - Adults age 75 and older with type 2 diabetes who are in poor health derive less benefit from tight glycemic control with insulin than their healthy peers, but they are more apt to be on insulin, a new study suggests.
While there is not "hard evidence," the American Diabetes Association recommends tailoring therapy and taking into account that sicker people probably need less aggressive therapy, Dr. Richard Grant, of the Division of Research, Kaiser Permanente of Northern California, Oakland, noted in a phone interview with Reuters Health.
"What we found was essentially the opposite, where the patients in poor health were less likely to have their insulin stopped than people in better health," said Dr. Grant. "As people get older and frail and have more comorbidities, some of the risks of treatment, particularly with insulin, start to outweigh the benefits."
The researchers used electronic health record data from the Kaiser Permanente Northern California diabetes registry to assess use and discontinuation of insulin treatment of 21,531 adults (48% women) aged 75 to 79 with type 2 diabetes.
The health status of each patient was defined as good (less than two comorbid conditions or two comorbidities but physically active), intermediate (more than two comorbidities or two comorbidities and no self-reported weekly exercise), or poor (end-stage pulmonary, cardiac, or renal disease or dementia or metastatic cancer).
Nearly one-fifth of the cohort (19%) used insulin. The likelihood of being on insulin at age 75 was higher among people in poor health (29.4%; adjusted risk ratio, 2.03; P
The researchers then looked at rates of discontinuation of insulin from age 75 to 79. "What we wanted to know was, when do we actually stop insulin? Do we keep it going until the grave?" said Dr. Grant.
The answer seems to be yes, for about two thirds of patients, as only one-third of insulin users at age 75 years discontinued insulin within four years of cohort entry (and at least six months prior to death).
The likelihood of continued insulin use was higher among individuals in poor health (aRR, 1.47; P
"These same prevalence and discontinuation patterns were present in the subset with tight glycemic control (hemoglobin A1c
"Persistent insulin use among older adults with poor health is associated with increased risk for hypoglycemia and limited future health benefit. Changes are needed in current practice to better align with guidelines that recommend reducing treatment intensity as health status declines," they conclude.
"Some patients," Dr. Grant told Reuters Health, "might not like the idea of pulling back on therapy; other patients might welcome it. When there isn't really strong evidence, there needs to be shared decision-making between the doctor and patient, taking into account the patient's values and preferences."
Funding for the study was provided by Kaiser Permanente of Northern California.
JAMA Intern Med 2019.(c) Copyright Thomson Reuters 2019. Click For Restrictions - https://agency.reuters.com/en/copyright.html