medwireNews: Older people with type 2 diabetes who initiate treatment with long-acting insulin analogs have a lower risk for severe hypoglycemia than those using neutral protamine Hagedorn (NPH) insulin, real-world study findings suggest.
Marie Bradley, from the US FDA in Silver Spring, Maryland, and colleagues evaluated Medicare data from 575,008 individuals aged 65 years or older (average 75 years) with type 2 diabetes who initiated insulin glargine (n= 407,018), insulin detemir (n=141,588), or NPH insulin (n= 26,402) between 2007 and 2019.
During a median follow-up of 0.37 years, there were 5194 cases of severe hypoglycemia requiring emergency department visits or hospitalization in the glargine group, along with 1693 in the detemir group, and 460 in the NPH group.
In a propensity score-weighted analysis, people in the glargine group had a significant 29% lower risk for severe hypoglycemia than those in the NPH group, with weighted incidence rates of 17.37 and 26.64 per 1000 person–years, respectively. Similarly, those taking detemir had a significant 28% reduced risk relative to those taking NPH, with corresponding weighted incidence rates of 16.69 and 25.04 per 1000 person–years.
“In terms of number needed to harm, one would need to treat 154 patients with glargine or 167 with detemir rather than with NPH insulin for a year to prevent 1 excess case of severe hypoglycemia,” explain the researchers in JAMA Internal Medicine.
They say that their findings contrast with previous study results showing similar rates of severe hypoglycemia among people with type 2 diabetes taking long-acting insulin analogs versus NPH insulin, and suggest that “age may have contributed to the disparity in study results.” Indeed, the previous study involved younger patients (average age 60 years), and Bradley and team say that there was “potential effect modification by age” in the current study, with the strongest protective association seen in people aged 69–87 years.
The study authors also note that prandial insulin significantly modified the protective association between long-acting insulin use and severe hypoglycemia risk, with no significant associations seen during times of prandial insulin use.
“This is an important finding and suggests that the advantages of long-acting analogs on hypoglycemia, observed in the main analysis, at least in certain age groups may not be seen if the patient initiates concomitant prandial insulin,” they write.
Bradley and team postulate that “[t]he inclusion of prandial insulin in type 2 diabetes treatment regimens may increase complexity, especially for older users, thereby increasing the possibility of using too much insulin, which might increase the likelihood of hypoglycemia to such an extent that the benefits from long-acting analogs compared with NPH insulin are lost.”
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JAMA Intern Med 2021; doi:10.1001/jamainternmed.2020.9176