National guidelines increasingly recommend deintensifying medical treatment among older adults, but these practices are challenging to implement.
By Janet Byron
OAKLAND, Calif. — Patients with type 2 diabetes who were in poor health were more likely to continue taking insulin after age 75 than their counterparts in better health, according to Kaiser Permanente research published today in JAMA Internal Medicine.
“Leading medical specialty organizations recommend reducing diabetes treatment intensity for older patients, particularly when they have multiple, life-limiting health conditions. But in current practice we found that these sicker patients were less likely to stop taking insulin,” said senior author Richard W. Grant, MD, MPH, research scientist with the Kaiser Permanente Division of Research in Oakland, California.
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. As people with type 2 diabetes age, however, the risks of insulin use can outweigh its benefits. 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 explained.
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 4 years.
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 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,” Dr. Grant said.
Pharmacists, primary care physicians, geriatric specialists, and others are working together to address “polypharmacy” — when older patients take 5 or more medications for multiple conditions — and to “deprescribe” medications by reducing doses or taking people off them, he added.
A recent Kaiser Permanente study showed that 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,” said Maisha S. Draves, MD, medical director of pharmacy for The Permanente Medical Group at Kaiser Permanente in Northern California.
In addition to Grant, co-authors on the study were Jonathan Z. Weiner, MD, MPH, Anjali Gopalan, MD, MS, Pranita Mishra, MPP, and Andrew J. Karter, PhD, Kaiser Permanente Northern California Division of Research; Kasia J. Lipska, MD, MHS, Yale School of Medicine; and Elbert S. Huang, MD, MPH, and Neda Laiteerapong, MD, University of Chicago.
This research was funded by the National Institute of Diabetes and Digestive and Kidney Diseases grant 5K24DK109114-02. Dr. Weiner was supported by the TPMG Delivery Science Fellowship Program.