Insulin Overutilization in Seniors with Type 2 Diabetes

Patients with type 2 diabetes who were in poor health were more likely to continue taking insulin after age 75 years than their counterparts in better health, according to Kaiser Permanente research published recently in JAMA Internal Medicine.

As people with type 2 diabetes age, the risks of insulin use can outweigh its benefits, creating the need for increased provider and patient education, the research says.

“Leading medical specialty organizations recommend reducing diabetes treatment intensity for older patients, particularly when they have multiple, life-limiting health conditions,” says Richard W. Grant, MD, MPH, research scientist with the Kaiser Permanente Division of Research in Oakland, California. “But in current practice we found that these sicker patients were less likely to stop taking insulin.”

Insulin is a hormone that helps the body regulate sugar in the blood and is a key component of treatment for many patients with type 2 diabetes. Older adults who continue to use insulin are at greater risk of dangerously low blood sugar, or hypoglycemia-this can happen when people take too large a dose of insulin, Grant says.

In the study, The Use and Discontinuation of Insulin Among Adults Aged 75–79 with Type 2 Diabetes: A Longitudinal Cohort Study, researchers followed 21,531 Kaiser Permanente members age 75 and older in Northern California who had type 2 diabetes. Nearly one-fifth of the patients used insulin at the beginning of the study, and among them, about one-third discontinued its use over the next four years. 

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The researchers grouped patients into three categories of health (poor, intermediate and good) using information in the medical record about the number of chronic conditions, functional status and indicators of end-stage disease.

Insulin use was highest among older adults in poor health, (29% of them used insulin) with a serious end-stage disease, or intermediate health (28% used insulin) with at least two other health conditions.

In contrast, just 11% of those in good health used insulin, the research says.

The findings were similar even when researchers took into account how well patients were controlling their blood sugar.

“Revisiting the need for potentially harmful medications such as insulin when the risks outweigh the benefits can help to reduce adverse events like hypoglycemia and improve the quality of care in older patients,” Grant says.

Pharmacists, primary care physicians, geriatric specialists, and others are working together to address “polypharmacy”-when older patients take five or more medications for multiple conditions-and to “de-prescribe” medications by reducing doses or taking people off them, he adds.

A recent Kaiser Permanente study showed discontinuing diabetes medications reduced the risk of hypoglycemia in elderly patients with well-controlled type 2 diabetes.

“We’re raising awareness about the need for physicians and patients to have conversations and reconsider medications that may lose benefit or add more risk as patients age,” says Maisha S. Draves, MD, medical director of pharmacy for The Permanente Medical Group at Kaiser Permanente in Northern California.