Abstract
BackgroundEvidence suggests that insulin therapy of patients with type 2 diabetes mellitus (T2DM) is frequently discontinued. However, the reasons for discontinuing insulin and factors associated with insulin discontinuation in this patient population are not well understood.MethodsWe conducted a retrospective cohort study of adults with T2DM prescribed insulin between 2010 and 2017 at Partners HealthCare. Reasons for discontinuing insulin and factors associated with insulin discontinuation were studied using electronic medical records (EMR) data. Natural language processing (NLP) was applied to identify reasons from unstructured clinical notes. Factors associated with insulin discontinuation were extracted from structured EMR data and evaluated using multivariable logistic regression.ResultsAmong 7009 study patients, 2957 (42.2%) discontinued insulin within 12 months after study entry. Most patients who discontinued insulin (2121 / 71.7%) had reasons for discontinuation documented. The most common reasons were improving blood glucose control (33.2%), achieved weight loss (18.5%) and initiation of non-insulin diabetes medications (16.7%). In multivariable analysis adjusted for demographics and comorbidities, patients were more likely to discontinue either basal or bolus insulin if they were on a basal-bolus regimen (OR 1.6, 95% CI 1.3 to 1.8; p < 0.001) or were being seen by an endocrinologist (OR 2.6; 95% CI 2.2 to 3.0; p < 0.001).ConclusionsIn this large real-world evidence study conducted in an area with a high penetration of health insurance, insulin discontinuation countenanced by healthcare providers was common. In most cases it was linked to achievement of glycemic control, achieved weight loss and initiation of other diabetes medications. Factors associated with and stated reasons for insulin discontinuation were different from those previously described for non-adherence to insulin therapy, identifying it as a distinct clinical phenomenon.
Highlights
Evidence suggests that insulin therapy of patients with type 2 diabetes mellitus (T2DM) is frequently discontinued
Study population We identified 8744 patients with diabetes mellitus treated with insulin in a primary care or endocrinology clinic affiliated with one of the study institutions
Second and third most common reasons for insulin discontinuation were likely related to blood glucose control as well: achieved weight loss leads to a decrease in insulin resistance and to lower blood glucose levels and insulin requirements [19], while initiation of additional non-insulin medications may achieve improved blood glucose control on its own, obviating the need for insulin
Summary
Evidence suggests that insulin therapy of patients with type 2 diabetes mellitus (T2DM) is frequently discontinued. The reasons for discontinuing insulin and factors associated with insulin discontinuation in this patient population are not well understood. Type 2 diabetes mellitus (T2DM) is a highly prevalent chronic disease with serious medical and economic burden [1,2,3]. The major focus of disease management in patients with T2DM is glycemic control, which might be initially achieved through lifestyle change and treatment with first-line metformin [4]. Due to the progressive nature of this chronic disease, many patients with T2DM eventually will require treatment intensification with other medications, including insulin [5]. Despite American Diabetes Association (ADA) guidelines and compelling evidence regarding the benefits of insulin therapy, insulin is underutilized in patients with T2DM. Alarming is the number of patients who stop insulin therapy in spite of poorly controlled hyperglycemia [8, 9]
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