Sulfonylurea Deintensification Rates Low After Hospitalization for Hypoglycemia

Anastasia-Stefania Alexopoulos, MBBS

The end goal of a recent study was to examine the deintensification of treatment with sulfonylurea and insulin, after a hypoglycemia-associated emergency department (ED) visit or hospitalization among older adults with diabetes.

Led by Anastasia-Stefania Alexopoulos, MBBS, Department of Medicine, Division of Endocrinology, Duke University, investigators observed sulfonylurea and/or insulin deintensification occurred in fewer than 50% of patients within the following 100 days after a hypoglycemia-associated ED visit or hospitalization.

Methods

Investigators analyzed medical claims, as well as prescription drug records, to include a random sample of 20% of nationwide fee-for-service Medicare beneficiaries.

The Medicare fee-for-service consisted of health insurance claims for patients with Medicare part A (inpatient services), part B (outpatient care), and part D (outpatient prescription drug) coverage. Beneficiaries who were included in the study were aged 65 years and older, with ≥1 hypoglycemia-associated ED visit or hospitalization between January 2007 - December 2017.

Included patients had at least 1 prescription for sulfonylurea, insulin, or both sulfonylurea and insulin within 6 months prior to the index date.

Primary outcomes were identified as the deintensification of treatment with sulfonylurea and/or insulin in the 100 days after a hypoglycemia-associated ED visit or hospitalization.

Accordingly, the study defined deintensification as either no prescription filled for baseline sulfonylurea and/or insulin within 100 days after the index event, a prescription filled for sulfonylurea within 100 days after the index event at a lower dose compared to the last prescription prior to the index event, or a change from long-acting sulfonylurea to glipizide within 100 days after the index event.

Findings

In the study, a total cohort of 76,728 distinct Medicare beneficiaries with a mean age of 76.6 years were identified. Data show among 106,293 total hypoglycemic episodes which required hospital attention, 69,084 (65.0%) occurred among women, 26,056 (24.5%) among Black individuals, 4761 (4.5%) among Hispanic individuals, 69,704 (65.6%) among White individuals.

It was shown that a total of 32,074 episodes (30.2%) occurred among those receiving sulfonylurea only, while 60,350 (56.8%) occurred among patients receiving insulin only and 13,869 (13.0%) occurred among those receiving both sulfonylurea and insulin.

Further, unadjusted incidence of treatment deintensification rates were the highest for individuals receiving both sulfonylurea and insulin therapies at time of their hypoglycemic episode (n = 6677, 48.1%), followed by sulfonylurea only (n = 14,192, 44.2%) and insulin only (n = 14,495, 24.0%).

Alexopoulos and colleagues observed an increase in treatment deintensification rates between 2007 - 2017 (sulfonylurea only: from 41.4% to 49.7%, P <.001 for trend; insulin only, from 21.3% to 25.9%, P <.001 for trend; sulfonylurea and insulin, from 45.9% to 49.6%, P = .005 for trend).

Additionally, lower socioeconomic status resulted in lower odds of deintensification (sulfonylurea only: AOR, 0.74, 95% CI, 0.70 - 0.78; insulin only, AOR 0.71, 95% CI, 0.68 - 0.75; sulfonylurea and insulin: AOR, 0.72, 95% CI, 0.66 - 0.78).

Other patient factors were associated with higher odds of treatment deintensification in those receiving sulfonylurea and insulin, including higher frailty (AOR, 1.50; 95% CI, 1.32 - 1.71), chronic kidney disease (AOR, 1.29; 95% CI, 1.19 - 1.40), a history of falls (AOR, 1.20; 95% CI, 1.09 - 1.33), and depression (AOR, 1.11; 95% CI, 1.02 - 1.20).

Takeaways

Investigators noted the potential of underestimates in deintensification rates, due to the inability in capturing changes in insulin dosing through claims data.

“Although there was a pattern of increasing sulfonylurea and/or insulin deintensification over a 10-year period, low overall rates of deintensification suggest that real-world practice may lag behind evidence that positions severe hypoglycemia as a major health and safety concern among older adults,” they wrote.

The study, “Deintensification of Treatment With Sulfonylurea and Insulin After Severe Hypoglycemia Among Older Adults With Diabetes,” was published in JAMA Network Open.