Prescribing Trends of Glucose-Lowering Medications Near End of Life Among Adults With Type 2 Diabetes: A Cohort Study

Abstract

Objective: To assess prescribing trends of glucose-lowering medications in the last year of life among older adults with type 2 diabetes (T2D) and explore whether frailty is associated with differential prescribing.

Research design and methods: In this observational cohort study of Medicare beneficiaries aged ≥67 years (2015-2019) with T2D, we assessed temporal trends in prescribing a glucose-lowering medication, stratified by frailty. The main outcome included glucose-lowering medication fills within 1 year of death.

Results: Among 975,407 community-dwelling Medicare beneficiaries with T2D, the use of glucose-lowering medications within 1 year of death slightly increased from 71.4% during the first 6-month period in 2015 to 72.9% (standardized mean difference [SMD] -0.03) during the second 6-month period in 2019. The most pronounced increase in use was observed for metformin (40.7% to 46.5%, SMD -0.12), whereas the largest decrease was observed for sulfonylureas (37.0% to 31.8%, SMD 0.11). Overall glucose-lowering medication use decreased from 66.1% in the 9 to 12 months before death to 60.8% in the last 4 months of life (SMD 0.11; P < 0.01), driven by reduced noninsulin medication use. The use of short-acting and long-acting insulin both increased near death, with frailer individuals more likely to receive insulin. Sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide 1 receptor agonists, although less common, became more frequent in more recent years.

Conclusions: The use of glucose-lowering medications declined in the last year of life, mainly due to reduced noninsulin use. Insulin use increased near death, particularly among frailer individuals, highlighting the need for careful end-of-life management.

Graphical abstract

Figure 1

Proportion of decedents on glucose-lowering medication 1 year before death, stratified by calendar time of death and according to level of frailty. A and D: Proportion of decedents on glucose-lowering medication 1 year before death among the overall study population with type 2 diabetes. B and E show findings for less frail people and C and F show findings for frailer people.

Figure 2

Longitudinal patterns in number of glucose-lowering medications (A, B, and C), short-acting insulin (D, E, and F), long-acting insulin (G, H, and I), metformin (J, K, and L), and sulfonylurea (M, N, and O) from −12 to −8 months to −4 to 0 months before death, overall and by level of frailty. The bars represent the proportions (%) of decedents with or without a glucose-lowering medication −12 to −8 months (left) and −4 to 0 months (right) before death.