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Given the well-documented and severe clinical consequences of iatrogenic hypoglycemia in older patients on insulin, the results of the present study suggest that efforts to define and implement insulin deprescribing guidelines in high-risk patients will likely be applicable to a substantial proportion of older patients with tight glycemic control despite poor health status and limited life expectancy.
Existing medication deprescribing guidelines provide frameworks for prescribers to contemplate deintensification but do not necessarily provide practical recommendations to implement this process into everyday practice. A recent review of medication deintensification tools noted that only 4 of 15 published guidelines were medication specific, 1 of 15 pertained to antihyperglycemic medicines, and none had high or moderate quality evidence supporting them. In contrast with insulin discontinuation, we found that insulin regimen simplification eg, from long-acting and short-acting insulin use to long-acting alone was relatively uncommon prevalence, 7.
This finding underscores the clinical utility of insulin regimen simplification to reduce hypoglycemia risk in certain situations when clinicians or patients are less willing to discontinue insulin. For example, patients with long-standing diabetes may become insulin-dependent owing to progressive beta-cell dysfunction. Patients with renal insufficiency may have contraindications to noninsulin medications, and their HbA 1c may be artificially low, which makes clinical decisions about insulin use more challenging.
In these situations, insulin regimen simplification may allow clinicians to prioritize practical aspects of diabetes management while also reducing risk of iatrogenic hypoglycemia. The results of this study must be interpreted in the context of the study design. First, the observational design precludes any definitive inference about causality. However, the cohort had few exclusion criteria and likely represents the general population better than that of a clinical trial.
Second, we studied an insured population in an integrated health system, which may limit generalizability, but using the KPNC closed pharmacy system allowed us to capture near-complete insulin prescribing information. Third, without being present with patients, we are unable to evaluate the discussion or lack thereof that informed the decision to continue or discontinue insulin therapy in this older, higher-risk patient population.
Rather, we provide a population-level perspective of the scope of insulin use in different older patient subgroups. Further work is now needed that can inform system-level efforts to guide safer and more standardized insulin continuation, discontinuation, and simplification frameworks for older patients. Fourth, because we measured insulin dispensing rather than insulin ordering, we were unable to determine whether insulin discontinuation was because of the clinician ie, stopped prescribing insulin or patient ie, stopped picking up prescriptions.
This measure has the advantage of capturing true discontinuation but requires further research to better understand the role of clinician vs patient in the discontinuation process. Fifth, despite robust pharmacy data, we were unable to examine insulin dose reductions because doses are not reliably captured in prescription information in the pharmacy data.
Finally, the health status classification scheme used EHR data and was susceptible to underrepresentation of medical comorbidities such as dementia, a condition often underdiagnosed. As the population with type 2 diabetes continues to age, there is a growing need for evidence-based treatment strategies related specifically to the use of insulin for these older patients. We found that the older adults in poorest health were most likely to use insulin and that subsequent insulin discontinuation was most common among healthier individuals.
The substantial and persistent insulin use among older adults with a high risk of hypoglycemia and limited future benefit suggests that more work is needed to develop systems-based approaches that support guideline-concordant insulin use in people older than 75 years. Corresponding Author: Jonathan Z.
Published Online: September 23, Author Contributions: Dr Weiner had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Critical revision of the manuscript for important intellectual content: All authors.
Dr Lipska reports receiving grants from the National Institutes of Health NIH and support from the Centers for Medicare and Medicaid Services to develop and evaluate publicly reported quality measures.
Dr Huang reports receiving grants from NIH. Dr Karter reports receiving grants from NIH. No other disclosures were reported. Download PDF Comment. Figure 1. Flowchart of Cohort Formation and Outcome Assessment. View Large Download. T1DM indicates type 1 diabetes mellitus. Figure 2. Figure 3. Table 1. Table 2.
Centers for Disease Control and Prevention. United States Diabetes Surveillance System. Accessed August 14, Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. Polypharmacy in the aging patient: a review of glycemic control in older adults with type 2 diabetes. Rates of complications and mortality in older patients with diabetes mellitus: the diabetes and aging study.
Predictors of nonsevere and severe hypoglycemia during glucose-lowering treatment with insulin glargine or standard drugs in the ORIGIN trial. Diabetes Care. Incidence of and risk factors for severe hypoglycaemia in treated type 2 diabetes mellitus patients in the UK: a nested case-control analysis.
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Rates of deintensification of blood pressure and glycemic medication treatment based on levels of control and life expectancy in older patients with diabetes mellitus.
Tight glycemic control and use of hypoglycemic medications in older veterans with type 2 diabetes and comorbid dementia. PubMed Google Scholar. The development of a standardized neighborhood deprivation index. J Urban Health. Defining adult overweight and obesity. Updated April 11, Accessed August 7, A new equation to estimate glomerular filtration rate. Association between estimated GFR, health-related quality of life, and depression among older adults with diabetes: the Diabetes and Aging Study.
Am J Kidney Dis. An algorithm to identify medication nonpersistence using electronic pharmacy databases. J Am Med Inform Assoc. Glycemic response to newly initiated diabetes therapies. Am J Manag Care. Review of deprescribing processes and development of an evidence-based, patient-centred deprescribing process.
Br J Clin Pharmacol. Reducing inappropriate polypharmacy: the process of deprescribing. Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. BMJ Open. Qual Health Res. Ann Fam Med. Assessment of attitudes toward deprescribing in older Medicare beneficiaries in the United States. Tools for deprescribing in frail older persons and those with limited life expectancy: a systematic review.
Views 11, Web of Science View Metrics. Twitter Facebook More LinkedIn. Original Investigation. Jonathan Z. Karter, PhD 1 ; Richard W. Key Points Question Is insulin treatment used less frequently and discontinued more often among older individuals with poor health compared with those in good health? The information provided by MedicallyAssisted. The views and opinions expressed on MedicallyAssisted.
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