Postprandial Insulin Initiation—Evaluation of Adverse Outcomes in Older Veterans

We assessed one-year adverse outcomes (emergency department visits for hypoglycemia (HYPO-ED), death) and potential overtreatment (A1c <6.5%) post prandial initiation in veterans >= 65 years receiving only basal insulin in 2009-2011 and dually enrolled in Veterans Health Administration and Medicare using linked data. Rates were compared 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 cardio vascular conditions (C)). 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; of the 271 (7.8%) deaths, 10.7%, 12.5%, and 25.8% occurred in the same time intervals. Of the 2,789 (80%) patients having some A1c values within a year post-prandial, 10% had an A1c <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 rates of having an A1c <6.5% (11.6% vs. 13.1%, p=0.48). Most (85%) patients had at least one of the studied comorbidity categories; the prevalence order was: C (69%), D (39%), M (21%), and L (16%). Patients with M (21%) had higher rates in adverse outcomes than those with only C (26%) and those without any studied comorbidities (15%): for HYPO-ED, the rates were 6.3%, 5.9%, and 5.4% (p=0.76); for death, 12.6%, 5.8%, and 2.3% (p<0.001); for having an A1c <6.5%, 14.5%, 11.8%, and 10.2% (p=0.11). 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%. Prandial insulin should be used cautiously in older adults with complex comorbidities.