How to avoid severe hypoglycemia in elderly patients with type 2 diabetes who started insulin

This article is from NEJM Journal Watch Severe Hypoglycemia in Older Patients with Type 2 Diabetes Who Are Initiating Insulin.
Comment on Severe Hypoglycemia in Older Patients with Type 2 Diabetes Who Are Initiating Insulin Author: Paul S.
Mueller, MD, MPH, FACP Among patients who started using long-acting insulin analogs, the incidence of severe hypoglycemia was lower than those who started using neutral protamine (NPH) insulin.

Evidence suggests that there is not necessarily a difference in the risk of severe hypoglycemia between patients with type 2 diabetes who use long-acting insulin analogues and those who use NPH insulin (NEJM JW Gen Med Aug 15 2018 and JAMA 2018; 320:53).

However, we know very little about this risk in the elderly (age, ≥65 years).

This retrospective cohort study included 575,000 people with type 2 diabetes who started using long-acting insulin analogues (407,000 people used insulin glargine, 142,000 people used insulin detemir) or NPH insulin (26,000 people).
Medicare) beneficiaries (average age, 75 years old), the investigators determined their risk of attending the emergency department and hospitalization due to hypoglycemia.

During the average follow-up period of less than 1 year, the total number of patients' visits to the emergency department and hospitalization due to hypoglycemia was 7,350 (5,200 for insulin glargine users, 1,700 for insulin detemir users, and 450 for NPH insulin users) .

Compared with users of NPH insulin, users of insulin glargine and insulin detemir have a 30% lower relative risk for emergency treatment and hospitalization.

In order to prevent one case of severe hypoglycemia, we need to use insulin glargine or insulin detemir instead of NPH for about 160 patients for one year.

However, when insulin glargine or insulin detemir is combined with prandial insulin, we no longer observe the protective association described above.

Comment In this study, compared with NPH insulin, the use of long-acting insulin analogues (insulin glargine or insulin detemir) in elderly patients with type 2 diabetes is associated with a lower risk of severe hypoglycemia.

However, the above-mentioned protective association was not seen in patients with insulin during meals.

For elderly patients with type 2 diabetes who need insulin, the American Diabetes Association recommends using basal insulin and avoiding mealtime insulin (Diabetes Care 2021; 44: Suppl 1: S168).

Commented article Bradley MC et al.
Severe hypoglycemia risk with long-acting insulin analogs vs neutral protamine Hagedorn insulin.
JAMA Intern Med 2021 Mar 1; [e-pub].
(https://doi.
org/10.
1001/jamainternmed.
2020.
9176 ) Related reading NEJM Journal Watch The NEJM Journal Watch is published by NEJM Group.
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