The data showed that only one-third of patients tapered off insulin use, underscoring a problem with medication overutilization and patient education.
Despite industry best practices to taper insulin use in seniors with multiple comorbidities, most patients over age 75 are still using the medication, revealing a need for better patient education about medication management, according to researchers from Kaiser Permanente.
Insulin is a key medication used to manage diabetes and is especially important for controlling type 2 diabetes, the research team said. However, as patients age and begin to develop other chronic illnesses, the benefits of insulin become overpowered by the risks of taking the drug while managing other comorbidities.
Specifically, older adults who use insulin are at greater risk of low blood sugar, or hypoglycemia, which usually happens when the patient has taken too large a dose of insulin. Previous data from Kaiser Permanente revealed that discontinuing insulin use can reduce the risk of hypoglycemia among older adults with type 2 diabetes, the research team acknowledged.
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To that end, most experts recommend patients and providers begin to taper off insulin use as the patient ages.
But most patients, especially those with multiple chronic illnesses, aren’t doing that, the researchers wrote in a new JAMA Internal Medicine study. After tracking insulin use habits of nearly 22,000 patients with diabetes age 75 or older, one-fifth of whom reported using insulin, the researchers found that only about one-third eventually tapered insulin use.
“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.
The team stratified the study participants into three broad categories, including those in poor, intermediate, or good health. Health status was determined by data in the EHR about patients’ chronic illnesses, functional status, or signs of end-stage disease.
Twenty-nine percent of those in the poor health group used insulin at study’s end, the highest rate among each group studied. These patients were categorized as showing signs of an end-stage disease.
Twenty-eight percent in the intermediate health group still used insulin by the end of the study. Researchers reported these patients had at least two other diseases.
Conversely, 11 percent of patients in the good health category used insulin at the study’s end.
These findings remained consistent even after researchers stratified based on how well patients controlled their blood sugar.
Patient education and patient-provider communication could help eliminate some of this problem, Grant said. Pharmacists and providers prescribing patients insulin should discuss the risks of continuing an insulin medication regimen as patients age and, using shared decision-making, help guide patients toward tapering off insulin use.
“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 explained.
“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,” Maisha S. Draves, MD, medical director of pharmacy for The Permanente Medical Group at Kaiser Permanente in Northern California, added.
Previous research has looked at medication overutilization among older adults. A 2017 AARP study related to dementia drugs cholinesterase inhibitors (ChEI) and memantine revealed that overutilization is caused largely by providers who don’t always know how to broach drug tapering with patients.
These conversations can be difficult for providers who may not want to appear like they are “giving up” on a patient or not giving their patient the best treatment throughout their entire lives. However, not understanding the cost and quality of life impacts of overprescribing medications at the end of life may not be best for patients, the researchers said.
Providers must understand patient needs and preferences, as well as the best clinical advice, to assess when to begin tapering off certain medications, especially when the drugs may be doing more harm than good or impacting quality of life.
“Health care providers must regularly assess patients and their prescription drug regimens to ensure regimens remain appropriate given changing health status and needs,” the AARP researchers concluded. “Accessible and up-to-date information on a drug’s effectiveness and side effects is essential to help increase the practice of de-prescribing medications that may no longer be of benefit, or even cause harm.”
Date: September 30, 2019
Source: Patient Engagement Hit