Persistence with rapid-acting insulin and its association with A1C level and severe hypoglycemia among elderly patients with type 2 diabetes

Abstract

Objective: To examine the persistence with rapid-acting insulin (RAI) and its association with clinical outcomes among elderly patients with type 2 diabetes (T2D).

Methods: This observational, retrospective cohort study analyzed RAI persistence and its association with change in glycated hemoglobin A1^c and risk of severe hypoglycemia among elderly (≥65 years) Medicare beneficiaries with T2D who added RAI to their basal insulin regimen.

Results: Among T2D patients with >1 RAI prescriptions (n = 3927), only 21% were persistent. Baseline factors positively associated with RAI persistence (adjusted odds ratio [95% CI]) were: age ≥75 vs. 65–74 years: 1.20 (1.01–1.43); use of ≥3 oral antidiabetes drugs: 1.63 (1.16–2.28); cognitive impairment: 1.34 (1.03–1.73); and A1C >9.0%: 1.58 (1.15–2.17). Elderly T2D patients having emergency department visits (0.73 [0.59–0.91]) and higher RAI out-of-pocket costs (≥$75 vs. $0 – <$6.40: 0.56 [0.44–0.70]) were less likely to be persistent. Persistent RAI users had a significantly higher reduction in A1C (beta coefficient [standard error]): −0.24 (0.10) and lower odds of severe hypoglycemia (adjusted odds ratio [95% CI]): 0.73 (0.53–0.99).

Conclusion: Among elderly T2D patients, persistence with RAI added to basal insulin was associated with improved glycemic control and lower risk of severe hypoglycemia. Despite treatment effectiveness, RAI persistence was poor and might be improved by reducing RAI out-of-pocket costs.

Keywords:

• Type 2 diabetes
• rapid-acting insulin
• persistence
• hypoglycemia
• A1C
• elderly

Transparency

Declaration of funding

Sponsorship for this study and article processing charges were funded by Sanofi US Inc. Any opinions, findings, and conclusions or recommendations expressed in this manuscript are those of the authors and do not necessarily reflect the views of the organizations that supported the study.

Author contributions: All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published.

Declaration of financial/other relationships

A.D. and R.G. have disclosed that they have no significant relationships with or financial interests in any commercial companies related to this study or article. US has disclosed that she has received grant funding from Sanofi US Inc. to perform this study. T.F. and A.B. have disclosed that they are employees of Sanofi US Inc., and A.B. was an employee of MannKind Corporation at the time of this research, is a stock holder of MannKind Corporation and Novo Nordisk Inc. and holds several methods of use patents for inhaled insulin.

Acknowledgments

The authors thank Steve Zhou of Sanofi US Inc. for his critical revision of this manuscript. The authors received writing and editorial support in the preparation of this manuscript from Pim Dekker PhD and Rasilaben Vaghjiani PhD of Excerpta Medica, funded by Sanofi US Inc.