Authors: W. David Strain, Angharad R. Morgan & Marc Evans
Abstract
Insulin represents a mainstay of glucose-lowering therapy for many adults with type 2 diabetes mellitus (T2DM). Insulin treatments prescribed as standard care for the majority of people with T2DM, such as basal human insulin, may not be optimal in the treatment of frail older adults because of the increased demand on health care staff to administer multiple daily injections and monitor the patient. When choosing an insulin regimen for a frail older person with T2DM, predictability of glucose lowering effect, risk of hypoglycaemia, ease of administration, and simplicity and flexibility of dosing are major determining factors. Multiple daily injections may be too complex for older frail adults, whilst providing an unnecessary degree of tight glycaemic control and low doses of once-daily basal insulin analogues such as insulin degludec may be a reasonable option as cognitive decline or functional disability increases. Although insulin degludec has a substantially higher acquisition cost than routinely used basal human insulin, it has a longer, more predictable pharmacological profile and is more amenable to once-daily administration, translating into a reduced burden of care and potential cost savings for insulin-treated frail older adults. Insulin acquisition cost represents only a small proportion of the total cost of treatment, and it is important to consider the value perspective of insulin therapy in frail older adults from all stakeholders in the health care system.
Key Summary Points |
There are several different insulin treatment options for type 2 diabetes in older adults; however, current available treatment strategies are derived from findings in younger adults that do not commonly present with the issues associated with frailty and age, such as cognitive impairment and the presence of physical disabilities. |
The presence of frailty, functional impairments, and cognitive decline in older adults with type 2 diabetes highlights the importance of community nursing support for insulin administration. |
The protracted duration of insulin degludec facilitates flexible dosing and convenience with once-daily administration, translating into clinical and economic value, particularly in frail older adults. |
Although insulin degludec has a substantially higher acquisition cost than basal human insulin, when considering the value of insulin, it is important to include insulin resource use beyond acquisition costs and, in particular, potential health care service use. |