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Research Letter |

Simplification of Insulin Regimen in Older Adults and Risk of Hypoglycemia

Medha N. Munshi, MD1,2,3; Christine Slyne, BA1; Alissa R. Segal, PharmD1,4; Nora Saul, RD1; Courtney Lyons, RN1; Katie Weinger, EdD1,3
[+] Author Affiliations
1Joslin Diabetes Center, Boston, Massachusetts
2Beth Israel Deaconess Medical Center, Boston, Massachusetts
3Department of Medicine, Harvard Medical School, Boston, Massachusetts
4School of Pharmacy, MCPHS University, Boston, Massachusetts
JAMA Intern Med. 2016;176(7):1023-1025. doi:10.1001/jamainternmed.2016.2288.
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This case series describes HbA1c levels and frequency of hypoglycemia among older patients with type 2 diabetes whose treatment regimen was simplified to once-a-day glargine with or without noninsulin agents.

Hypoglycemia is a serious adverse event, especially in older patients with diabetes, and is associated with poor outcomes.1 Intensive insulin regimens add a large burden of self-care to older patients and increase the risk of hypoglycemia.2,3 Treatment guidelines and expert consensus recommend deintensification of treatment regimens in older adults.4 However, the effect of insulin regimen simplification on the risk of hypoglycemia or uncontrolled hyperglycemia is not known. In addition, the lack of an algorithm to guide insulin regimen simplification may account for missed opportunities to deintensify insulin regimens in older patients with diabetes.5

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Algorithm for Insulin Regimen Simplification

Insulin regimen simplification is achieved in this algorithm by changing to or adding glargine as basal insulin and adding noninsulin agents to replace meal-time insulins. Long-acting insulins include insulin detemir (Levemir; Novo Nordisk) and Neutral Protamine Hagedorn insulin. Meal-time insulins include insulin lispro (Humalog; Lilly), insulin aspart (NovoLog; Novo Nordisk), and insulin glulisine (Apidra; Sanofi-Aventis) All patients were 65 years or older with type 2 diabetes, took 2 or more insulin injections/d, and had at least 1 episode of hypoglycemia (glucose level <70 mg/dL) during a 5-day period of continuous glucose monitoring.

aManagement of hyperglycemia in type 2 diabetes, 2015: a patient-centered approach: update to a position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) (http://www.ncbi.nlm.nih.gov/pubmed/25538310). Further simplification agents were chosen based on risk of hypoglycemia, cost, adverse-effect profile, effect on weight, and effectiveness, as recommended.

bIf fasting glucose levels are higher than the goal but prelunch or dinner glucose levels reach the goal, change the glargine dose to bedtime at the same dose.

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