Risk with Basal Insulin in Older Diabetics

Hypoglycemia during the first year of basal insulin treatment is associated with the risk of hospitalization or death in older people with type 2 diabetes mellitus (T2DM), according to a new study.

The use of insulin is associated with an increased risk of hypoglycemia, and therefore physicians often adopt an overly cautious approach to prescribing insulin. Many patients prefer to delay insulin therapy because they fear hypoglycemia, and others may reduce their insulin dose following an episode of hypoglycemia, state the researchers, led by Dr. Javier Escalada of the Clínica Universidad de Navarra in Pamplona, Spain.

“Older patients with type 2 DM are at increased risk of experiencing severe hypoglycemic events compared with younger groups, a concern that is further augmented upon basal insulin initiation,” the researchers stated, adding that adults over age 75 are almost three times as likely to present to an emergency department due to hypoglycemia as compared with the overall adult diabetic population. With an aging population, the investment required to manage insulin-related hypoglycemia is expected to escalate, they noted.

The researchers conducted a retrospective analysis of a Medicare Advantage insurance claims database of 31,035 patients, mean age 72 years, initiating basal insulin treatment. They assessed the influence of comorbidities and drug pattern use on hypoglycemic risk, the consequences of hypoglycemia in terms of hospitalization and mortality rates, as well as healthcare utilization and the economic impact of hypoglycemia.

The patients were stratified into those with medically attended hypoglycemia during the first year of basal insulin treatment and those without hypoglycemia.

Of the 31,035 patients, 3,066 experienced hypoglycemia during 1 year post-basal insulin initiation. After adjustment for demographic, comorbidity and medication history, hypoglycemia was associated with a risk of hospitalization and death.

Healthcare utilization was higher pre-index and showed greater increases post-basal insulin initiation in the hypoglycemia group as compared to the non-hypoglycemia group. Per-patient healthcare costs were substantially higher for the hypoglycemia group than the non-hypoglycemia group, both pre-index ($54,057 vs $30,249, respectively) and post-basal insulin initiation ($75,398 vs $27,753, respectively).

In conclusion, the researchers stated: “Collectively, these results highlight the burden of hypoglycemia for patients with type 2 diabetes initiating basal insulin, both in terms of health outcomes and in resource utilization and direct costs. Furthermore, in this older population, those with high levels of comorbidity are particularly vulnerable to hypoglycemia. Strategies to reduce hypoglycemic risk in this fragile older population, and the impact on health outcomes, need to be investigated.”

They noted that new basal insulins are in development that may provide a more stable, prolonged delivery of the drug, avoiding the peaks and troughs of activity that may lead to episodes of hypoglycemia.

Better basal insulins plus low-risk anti-hyperglycemic drugs, such as glucagon-like peptide-1 agonists, may be a better treatment option than prandial insulin or high-risk oral drugs in patients susceptible to hypoglycemia. “Choice of agents in combination therapy should also be carefully considered for older patients where hypoglycemic events are likely to lead to adverse outcomes,” they stated.

Reference: Escalada J, et al. Outcomes and healthcare resource utilisation associated with medically attended hypoglycaemia in older patients with type 2 diabetes initiating basal insulin in a US managed care setting. Curr Med Res Opin. 2016 May 12:1-30.