Clinical Topics

Cautious Use of Prandial Insulin Urged for Older Veterans

by U.S. Medicine

August 19, 2018

EAST ORANGE, NJ—A new VA study pointed out why prandial insulin should be used cautiously in older adults with complex comorbidities.

The study presented at the recent American Diabetes Association 78th Scientific Sessions in Orlando and printed in a special supplement to the journal Diabetes assessed one-year adverse outcomes —emergency department visits for hypoglycemia (HYPO-ED), death) and potential overtreatment (A1c < 6.5% —of post-prandial initiation in veterans 65 or older receiving only basal insulin. The study, looking at the years 2009-2011, involved dually enrolled in Veterans Health Administration and Medicare using linked data.

Researchers from the VA New Jersey Health Care System-East Orange compared rates by race, blacks, whites, others, and comorbidity categories —advanced diabetes complications (D), diminished life expectancy (L), major neurological disorders/dementia/cognitive impairment/major depression/substance abuse (M) and cardiovascular conditions (C)).

Results indicated that, of the 3,465 studied patients, 457 (13%) died or incurred HYPO-ED. Of the 200 (5.8%) that incurred HYPO-ED, 16%, 24.5%, and 23% had the event within 1, 2-3, and 4-6 months, respectively, the researchers noted. Of the 271 (7.8%) deaths, 10.7%, 12.5%, and 25.8% occurred in the same time intervals, the study pointed out.

At the same time, of the 2,789 (80%) patients having some A1c values within a year post-prandial, 10% had an A1c of less than 6.5%. Compared to whites (n=2,708; 78%), blacks (336; 10%) had a higher HYPO-ED rate (8.0% vs. 5.6%, p=0.08) and a comparable death rate (8.6% vs. 8.4%, p=0.88).Both races had similar risks of having an A1c less than 6.5%—11.6% vs. 13.1%.

Study authors wrote that most, 85%, of the patients had at least one of the studied comorbidity categories; the prevalence order was:

  • cardiovascular conditions, 69%;
  • advanced diabetes complications, 39%;
  • depression/substance abuse, 21%; and
  • diminished life expectancy, 16%.

The report noted that patients with depression/substance abuse had higher rates in adverse outcomes than those with only cardiovascular conditions and those without any studied comorbidities. That also was the case for hypoglycemia and having an A1c less than 6.5%. The difference was especially stark for mortality: 12.6% for patients with depression/substance abuse compared to 5.9% for those with cardiovascular conditions and 2.3% for those with neither.

“Among basal insulin users started on prandial, we found that within a year after prandial initiation, HYPO-ED rate was 1.4 fold greater in blacks than whites, patients with mental/cognitive/neurological diseases had higher rates in HYPO-ED and death, and at least one in ten had an A1c <6.5%,” study authors emphasized. “Prandial insulin should be used cautiously in older adults with complex comorbidities.”

1. Tseng C-L, Soroka O, Pogach L. Postprandial Insulin Initiation—Evaluation of Adverse Outcomes in Older Veterans. Diabetes 2018 Jul; 67(Supplement 1): https://doi.org/10.2337/db18-403

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