Should insulin be removed from the treatment regimen of an 80-year-old patient with type 2 diabetes, multiple cardiovascular comorbidities, and hypothyroidism?

Should Insulin Be Removed?

For this 80-year-old patient with type 2 diabetes and multiple cardiovascular comorbidities, insulin should be simplified or discontinued entirely if the patient is on a complex regimen (basal-bolus or premixed insulin) and the HbA1c is below 8.0%, as this represents overtreatment that increases mortality risk from hypoglycemia without providing clinical benefit. 1

Immediate Assessment Required

Before making any changes, you must determine:

• Current HbA1c level - This is the single most important factor in deciding whether to remove insulin 1, 2
• Current insulin regimen complexity - Is the patient on basal-bolus, premixed, or simple basal insulin only? 3
• Cognitive and functional status - Can the patient or caregiver safely manage the current regimen? 3
• History of hypoglycemia - Any episodes requiring assistance from others? 3

Decision Algorithm Based on HbA1c

If HbA1c is <7.5%

Remove insulin immediately. This represents dangerous overtreatment in an 80-year-old with multiple comorbidities. 1, 2 The American Geriatrics Society has identified tight glycemic control (HbA1c <7.0%) in elderly patients as causing falls, fractures, cognitive impairment, and cardiovascular events with mortality risk exceeding any benefit. 1

If HbA1c is 7.5-8.0%

Simplify the insulin regimen aggressively. 3 If the patient is on basal-bolus or premixed insulin:

• Calculate total daily insulin dose 1
• Convert to 70% of that dose as basal insulin only (glargine, detemir, or degludec) 1
• Administer once daily in the morning 1
• This approach reduces hypoglycemia and disease-related distress without worsening glycemic control 3

If HbA1c is 8.0-8.5%

This is the appropriate target for this patient. 1, 4 The Endocrine Society considers this acceptable for patients with multiple comorbidities. 1 Simplify to once-daily basal insulin if currently on a complex regimen. 3

If HbA1c is >8.5%

Maintain simplified insulin therapy (once-daily basal insulin), but do not intensify to basal-bolus regimens. 3 Multiple daily injections are too complex for older patients with advanced complications and life-limiting chronic illnesses. 3

Critical Considerations for This 80-Year-Old Patient

Overtreatment is extremely common and dangerous in this population. Studies demonstrate that intensive glycemic control in older adults with multiple medical conditions increases mortality without clinical benefit. 3 The American Diabetes Association explicitly states that no randomized controlled trials have shown benefits of tight glycemic control on clinical outcomes and quality of life in elderly patients, while hypoglycemia clearly increases morbidity and mortality. 3, 4

Cardiovascular risk factor control matters more than glycemic control. Greater reductions in morbidity and mortality result from controlling hypertension and dyslipidemia rather than from tight glycemic control alone in this age group. 3

If Patient is Also on Other Diabetes Medications

If on a GLP-1 receptor agonist (like Ozempic): Remove or drastically reduce insulin immediately. 1 The combination creates unacceptably high hypoglycemia risk that outweighs any glycemic benefit. Continue the GLP-1 receptor agonist as it has minimal hypoglycemia risk. 1

If on metformin: Continue metformin if eGFR ≥30 mL/min/1.73 m². 3 Metformin is the first-line agent for older adults and should be maintained unless contraindicated. 3

If on sulfonylureas: Discontinue these immediately. 1 Sulfonylureas increase hypoglycemia risk unacceptably in elderly patients and should be avoided entirely. 3, 1

Common Pitfalls to Avoid

Do not maintain the current regimen "because it's been working." 3 What worked at age 60 may be lethal at age 80. Functional status, cognitive ability, and life expectancy change dramatically, requiring deintensification. 3

Do not target HbA1c <7.0% in this patient. 1, 4 This is associated with increased mortality without clinical benefit in elderly patients with multiple comorbidities. 3, 1

Do not abruptly stop all diabetes medications without a plan. 3 If removing insulin, ensure metformin is continued (if not contraindicated) and establish a monitoring plan. 3

Monitoring After Insulin Removal or Simplification

• Check fasting glucose daily for the first week after any change 1
• Target fasting glucose of 90-150 mg/dL (not the tighter targets used in younger patients) 1
• Recheck HbA1c in 3 months to ensure glycemic control remains acceptable 2
• Educate patient/caregivers about hyperglycemia symptoms that would warrant reassessment 2

Special Circumstances

If the patient has cognitive impairment or limited self-care ability: Target HbA1c of 8.0-8.5% and simplify to once-daily basal insulin at most. 1 Consider whether even this is necessary based on current HbA1c. 3

If the patient is receiving palliative care or has end-stage disease: Discontinue all diabetes medications except minimal basal insulin to prevent acute hyperglycemic symptoms only. 3, 1 The focus should be on avoiding symptoms and complications from glycemic management, not on achieving any specific HbA1c target. 3