Type 2 diabetes mellitus treatment patterns in US nursing home residents

Comparative safety and cardiovascular effectiveness of sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists in nursing homes

AIM

Studies examining the safety and effectiveness of sodium-glucose cotransporter-2 inhibitors (SGLT2is) versus glucagon-like peptide-1 receptor agonists (GLP-1RAs) among community-dwelling adults may not generalize to nursing home (NH) residents, who are typically older and more multimorbid. We compared the safety and cardiovascular effectiveness of SGLT2is and GLP-1RAs among US NH residents.

MATERIALS AND METHODS

Eligible individuals were aged ≥66 years with type 2 diabetes mellitus and initiated an SGLT2i or GLP-1RA in an NH between 2013 and 2018. Safety outcomes included fall-related injuries, hypoglycaemia, diabetic ketoacidosis (DKA), urinary tract infection or genital infection, and acute kidney injury in the year following treatment initiation. Cardiovascular effectiveness outcomes included death, major adverse cardiovascular events and hospitalization for heart failure. Per-protocol adjusted hazard ratios (HR) were calculated using stabilized inverse probability of treatment and censoring weighted cause-specific hazard regression models accounting for 127 covariates.

RESULTS

The study population included 7710 residents (31.08% SGLT2i, 68.92% GLP-1RA). Compared with GLP-1RA initiators, SGLT2i initiators had higher rates of DKA (HR 1.95, 95% confidence limits 1.27, 2.99) and death (HR 1.18, 95% confidence limits 1.02, 1.36). Rates of urinary tract infection or genital infection, acute kidney injury, major adverse cardiovascular events, and heart failure were also elevated, while rates of fall-related injuries and hypoglycaemia were reduced, but all estimates were imprecise and highly compatible with no difference.

CONCLUSIONS

SGLT2is do not have superior, and may have inferior, effectiveness compared with GLP-1RAs for cardiovascular and mortality outcomes in NH residents. Residents initiating SGLT2is should be monitored closely for DKA.

National trends in utilisation of glucose lowering medicines by older people with diabetes in long-term care facilities

AIMS

To examine national trends in glucose lowering medicine (GLM) use among older people with diabetes in long-term care facilities (LTCFs) during 2009-2019.

METHODS

A repeated cross-sectional study of individuals ≥65 years with diabetes in Australian LTCFs (n = 140,322) was conducted. Annual age-sex standardised prevalence of GLM use and number of defined daily doses (DDDs)/1000 resident-days were estimated. Multivariable Poisson or Negative binomial regression models were used to estimate adjusted rate ratios (aRRs) and 95 % confidence intervals (CIs).

RESULTS

Prevalence of GLM use remained steady between 2009 (63.9%, 95 %CI 63.3-64.4) and 2019 (64.3%, 95 %CI 63.9-64.8) (aRR 1.00, 95 %CI 1.00-1.00). The percentage of residents receiving metformin increased from 36.0% (95 %CI 35.3-36.7) to 43.5% (95 %CI 42.9-44.1) (aRR 1.01, 95 %CI 1.01-1.01). Insulin use also increased from 21.5% (95 %CI 21.0-22.0) to 27.0% (95 %CI 26.5-27.5) (aRR 1.02, 95 %CI 1.02-1.02). Dipeptidyl peptidase-4 inhibitor use increased from 1.0% (95 %CI 0.9-1.1) to 21.1% (95 %CI 20.7-21.5) (aRR 1.24, 95 %CI 1.24-1.25), while sulfonylurea use decreased from 34.4% (95 %CI 33.8-35.1) to 19.3% (95 %CI 18.9-19.7) (aRR 0.93, 95 %CI 0.93-0.94). Similar trends were observed in DDDs/1000 resident days.

CONCLUSIONS

The increasing use of insulin and ongoing use of sulfonylureas suggests a need to implement evidence-based strategies to optimise diabetes care in LTCFs.

Sliding Scale Insulin Use in Nursing Homes Before and After Onset of the COVID-19 Pandemic

OBJECTIVE

To characterize sliding-scale insulin (SSI) use in US nursing homes (NHs) before and after the COVID-19 pandemic.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

A total of 129,829 US NH residents on SSI (01/2018-06/2022) across 12 NH chains with a common electronic health record system.

METHODS

Among all residents with at least 1 administration of SSI documented in the electronic medication administration record, we described resident demographics, frequency of SSI monotherapy vs combination therapy with another diabetes medication, number of daily capillary blood glucose readings ("fingersticks"), and hypoglycemia (capillary blood glucose <70 mg/dL) and hyperglycemia after first SSI use. We used interrupted time series analysis (ITS) with segmented linear regression models to examine whether the monthly prevalence of SSI use changed at and after the onset of the COVID-19 pandemic (March 2020).

RESULTS

There were 129,829 unique NH residents with SSI use [51% women, average age 71.3 (SD 11.7) years]. Of these, 36% of residents received SSI monotherapy and 64% received SSI combination therapy. Residents on SSI received an average of 3.96 (SD 1.41) fingersticks per day. Overall, 26% of SSI users experienced a hypoglycemic event within 30 days of the first SSI dose. The ITS analysis identified a step decrease in the rate of SSI use following the onset of the COVID-19 pandemic (43 fewer SSI users per 1000 insulin users) but no change in overall trend over time from before the onset of the pandemic.

CONCLUSIONS AND IMPLICATIONS

SSI use and fingerstick burden are high in NH residents. Hypoglycemia occurred commonly among residents on SSI. Future research should compare the safety and effectiveness of SSI monotherapy vs other diabetes medication regimens to guide person-centered prescribing decisions in NHs.

Comparative safety of sulfonylureas among U.S. nursing home residents

BACKGROUND

The comparative safety of sulfonylureas (SUs) in nursing home (NH) residents remains understudied despite widespread use. We compared the effects of three SU medications and initial SU doses on adverse glycemic and cardiovascular events among NH residents.

METHODS

This national retrospective cohort study linked Medicare claims with Minimum Data Set 2.0 assessments for long-stay NH residents aged ≥65 years between January 2008 and September 2010. Exposures were the SU medication initiated (glimepiride, glipizide, or glyburide) and doses (standard or reduced). One-year outcomes were hospitalizations or emergency department visits for severe hypoglycemia, heart failure (HF), stroke, and acute myocardial infarction (AMI). After the inverse probability of treatment and inverse probability of censoring by death weighting, we estimated hazard ratios (HR) using Cox regression models with robust 95% confidence intervals (CI).

RESULTS

The cohort (N = 6821) included 3698 new glipizide, 1754 glimepiride, and 1369 glyburide users. Overall, the mean (standard deviation) age was 81.4 (8.2) years, 4816 (70.6%) were female, and 5164 (75.7%) were White non-Hispanic residents. The rates of severe hypoglycemia were 30.3 (95% CI 22.3-40.1), 49.0 (95% CI 34.5-67.5), and 35.9 (95% CI 22.2-54.9) events per 1000 person-years among new glipizide, glimepiride, and glyburide users, respectively (glimepiride versus glipizide HR 1.6, 95% CI 1.0-2.4, p = 0.04; glyburide versus glipizide HR 1.2, 95% CI 0.7-1.9, p = 0.59). The rates of severe hypoglycemia were 27.1 (95% CI 18.6-38.0) and 42.8 (95% CI 33.6-53.8) events per 1000 person-years among new users of reduced and standard SU doses, respectively (HR 2.2, 95% CI 1.4-3.5, p < 0.01). Rates of HF, stroke, and AMI were similar between medications and doses.

CONCLUSIONS

Among long-stay NH residents, new use of glimepiride and standard SU doses resulted in higher rates of severe hypoglycemic events. Cardiovascular outcomes may not be affected by the choice of SU medication or dose.

Ten-Year Prospective Follow-Up of Institutionalized Patients With Diabetes in a Long-Term Care Home

Clinical practice recommendations advise individualizing diabetes treatment for elderly people, especially those living in long-term care facilities. Elderly patients face one of two main risks: either excessive treatment leading to hypoglycemia or insufficient treatment leading to progression of complications and excess mortality. This article describes a 10-year prospective observational study of people with diabetes in a long-term care home to determine the effect of routine glucose monitoring and monthly evaluation by a diabetes specialist with a goal of improving A1C. Its findings suggest that minimal glucose monitoring and monthly medical follow-up can optimize patient outcomes and help to maintain quality of life without over-medicalization of older people with diabetes in institutional settings.

Fingerstick glucose monitoring by cognitive impairment status in Veterans Affairs nursing home residents with diabetes

BACKGROUND

Guidelines recommend nursing home (NH) residents with cognitive impairment receive less intensive glycemic treatment and less frequent fingerstick monitoring. Our objective was to determine whether current practice aligns with guideline recommendations by examining fingerstick frequency in Veterans Affairs (VA) NH residents with diabetes across cognitive impairment levels.

METHODS

We identified VA NH residents with diabetes aged ≥65 residing in VA NHs for >30 days between 2016 and 2019. Residents were grouped by cognitive impairment status based on the Cognitive Function Scale: cognitively intact, mild impairment, moderate impairment, and severe impairment. We also categorized residents into mutually exclusive glucose-lowering medication (GLM) categories: (1) no GLMs, (2) metformin only, (3) sulfonylureas/other GLMs (+/- metformin but no insulin), (4) long-acting insulin (+/- oral/other GLMs but no short-acting insulin), and (5) any short-acting insulin. Our outcome was mean daily fingersticks on day 31 of NH admission.

RESULTS

Among 13,637 NH residents, mean age was 75 years and mean hemoglobin A1c was 7.0%. The percentage of NH residents on short-acting insulin varied by cognitive status from 22.7% in residents with severe cognitive impairment to 33.9% in residents who were cognitively intact. Mean daily fingersticks overall on day 31 was 1.50 (standard deviation = 1.73). There was a greater range in mean fingersticks across GLM categories compared to cognitive status. Fingersticks ranged widely across GLM categories from 0.39 per day (no GLMs) to 3.08 (short-acting insulin), while fingersticks ranged slightly across levels of cognitive impairment from 1.11 (severe cognitive impairment) to 1.59 (cognitively intact).

CONCLUSION

NH residents receive frequent fingersticks regardless of level of cognitive impairment, suggesting that cognitive status is a minor consideration in monitoring decisions. Future studies should determine whether decreasing fingersticks in NH residents with moderate/severe cognitive impairment can reduce burdens without compromising safety.

Diabetes management of older adults in nursing homes: A retrospective study

AIM

To examine the diabetes management of older adults in nursing homes.

BACKGROUND

Diabetes is an increasing problem in nursing homes, and diabetes care is defined as a neglected clinical area.

METHODS

A retrospective collected data review of 166 older adults with known diabetes from four nursing homes.

RESULTS

65% older than 75 years had HbA1c levels lower than 7.5% (58 mmol/mol), 74% older than 85 years had HbA1c levels lower than 8% (64 mmol/mol). The HbA1c levels were 7.3% (56 mmol/mol) for those who had three and more chronic disorders and 6.8% (51 mmol/mol) for those who had less than three chronic disorders. Individuals treated with insulin had higher HbA1c levels (p < .001) and glycaemia (p = .002). Age was associated with a number of chronic disorders (p = .031), a number of regularly prescribed medications (p = .038) and a number of medications as needed (p = .009).

CONCLUSIONS

More than half to three quarters have diabetes well-managed. Nevertheless, there is still some potential for improving diabetes care, and these findings warrant further research for improving diabetes management of older adults in nursing homes.

IMPLICATIONS FOR NURSING MANAGEMENT

Interventions designed to promote a healthy lifestyle, documenting individuals' target level and regular monitoring of glycaemia and HbA1c levels may help to improve diabetes management, which may result in better well-being and quality of life for older adults with diabetes in nursing homes.

Metformin Safety Warnings and Diabetes Drug Prescribing Patterns for Older Nursing Home Residents

OBJECTIVE

Diabetes mellitus is common in US nursing homes (NHs), and the mainstay treatment, metformin, has US Food and Drug Administration (FDA) boxed warnings indicating safety concerns in those with advanced age, heart failure, or renal disease. Little is known about treatment selection in this setting, especially for metformin. We quantified the determinants of initiating sulfonylureas over metformin with the aim of understanding the impact of FDA-labeled boxed warnings in older NH residents.

DESIGN AND SETTING

National retrospective cohort in US NHs.

PARTICIPANTS

Long-stay NH residents age ≥65 years who initiated metformin or sulfonylurea monotherapy following a period of ≥6 months with no glucose-lowering treatment use between 2008 and 2010 (n = 7295).

MEASUREMENTS

Measures of patient characteristics were obtained from linked national Minimum Data Set assessments; Online Survey, Certification and Reporting (OSCAR) records; and Medicare claims. Odds ratios (ORs) comparing patient characteristics and treatment initiation were estimated using univariable and multivariable multilevel logistic regression models with NH random intercepts.

RESULTS

Of the 7295 residents in the study population, 3066 (42%) initiated metformin and 4229 (58%) initiated a sulfonylurea. In multivariable analysis, several factors were associated with sulfonylurea initiation over metformin initiation, including heart failure (odds ratio [OR] 1.2, 95% confidence interval [CI] 1.1-1.4) and renal disease (OR 2.1, 95% CI 1.7-2.5). Compared with those aged 65 to <75 years, residents 75 to <85 (OR 1.3, 95% CI 1.2-1.5), 85 to <95 (OR 2.0, 95% CI 1.7-2.3), and ≥95 (OR 4.3, 95% CI 3.2-5.8) years were more likely to initiate sulfonylureas over metformin.

CONCLUSIONS

In response to FDA warnings, providers initiated NH residents on a drug class with a known, common adverse event (hypoglycemia with sulfonylureas) over one with tenuous evidence of a rare adverse event (lactic acidosis with metformin).

HYPERGLYCEMIA AND HYPOGLYCEMIA IN PATIENTS WITH DIABETES IN SKILLED NURSING FACILITIES

OBJECTIVE

Endocrinologists are faced with a growing elderly patient population with diabetes mellitus (DM), some of whom are in skilled nursing facilities (SNFs). Efforts at managing their DM is hampered by concerns for hypoglycemia. This study aimed to determine the frequency of hypo- and hyperglycemia in SNFs, and associated factors.

METHODS

We reviewed medical records of 200 consecutive residents admitted to two SNFs in the Cleveland area in 2014 with documented DM, aged ≥65 years. Data collected included blood glucose (BG) levels and DM regimens. Frequency of hyper- and hypoglycemic events was noted. Since patients had different frequencies of BG checks, event-days were calculated.

RESULTS

Mean age, BG, and glycated hemoglobin (±SD) were as follows: 80.2 ± 8.2 years, 172.4 ± 40.3 mg/dL, and 7.5 ± 1.9% (59 mmol/mol), respectively. Seventy-one percent were on insulin alone, 15.5% on insulin and oral diabetes agents, and 13.5% on oral diabetes agent on admission. Patients with at least one event were as follows: 38% hypoglycemia, 3.5% severe hypoglycemia, 90.5% hyperglycemia, and 15% severe hyperglycemia. Event-days were: 3.4% hypoglycemia and 52.4% hyperglycemia. Risk of hypoglycemia was highest with concomitant sulfonylurea and prandial or sliding-scale insulin. Hyperglycemia risk was high in basal insulin-containing regimens.

CONCLUSION

Hypoglycemia was seen in one-third of patients, and hyperglycemia was common despite insulin use. Concomitant use of sulfonylurea and prandial or sliding-scale insulin is best avoided in this fragile population with hypo- and hyperglycemia.

ABBREVIATIONS

ADA = American Diabetes Association BG = blood glucose DM = diabetes mellitus GLP-1 = glucagon-like peptide 1 HBA1c = glycated hemoglobin LOS = length of stay NPH = neutral protamine Hagedorn SNF = skilled nursing facility SSI = sliding-scale insulin.

National Trends in Treatment Initiation for Nursing Home Residents With Diabetes Mellitus, 2008 to 2010

OBJECTIVE

Diabetes mellitus is common in the nursing home (NH) population, yet little is known about prescribing of glucose-lowering medications in the NH setting. We describe trends in initiation of glucose-lowering medications in a national cohort of NH residents.

DESIGN AND SETTING

Retrospective cohort study using Part A and D claims for a random 20% of Medicare enrollees linked to NH Minimum Data Set (MDS) and Online Survey, Certification, and Reporting (OSCAR) databases in 7158 US NHs.

PARTICIPANTS

A total of 11,531 long-stay (continuous residence of ≥90 days) NH residents 65 years or older with diabetes who received a glucose-lowering medication between 2008 and 2010 after 4 months of nonuse.

MEASUREMENTS

Medicare Part D drug dispensing of glucose-lowering treatments; resident and facility characteristics preceding medication initiation.

RESULTS

We observed decreasing sulfonylurea initiation from 25.4% of initiations in 2008 to 11.7% in 2010, an average decrease of 1% per quarter (95% CLs -1.5 to -0.5). Thiazolidinedione initiation decreased from 4.7% to 1.9%, an average decrease of 0.3% per quarter (95% CLs -0.4 to -0.2), and meglitinide initiation from 1.5% to 0.3%. No appreciable linear trends were observed for metformin (range 12.0%-18.8%) and dipeptidyl peptidase-4 (DPP-4) inhibitors (range 0.9%-2.7%). In contrast, insulin use increased from 51.7% to 68.3% during the same time period, driven by a marked increase in initiation of rapid-acting insulin (11.0% to 29.4%; average increase of 1.4% per quarter, 95% CLs 0.9-1.9) and a modest increase in short-acting insulin (22.6% to 30.3%; an average increase of 0.6% per quarter, 95% CLs -0.1 to 1.3).

CONCLUSIONS

Between 2008 and 2010, there were substantial decreases in the use of oral glucose-lowering agents and corresponding increases in the use of insulin among long-term residents of US NHs.