Deintensifying Glycemic Goals and Treatment Regimens in Older Adults

by Cameron Hammers, Doctor of Pharmacy Candidate, and Stuart T Haines, PharmD, BCPS, BCACP, University of Mississippi School of Pharmacy

Older adults taking antihyperglycemics are inherently at a higher risk for hypoglycemia due to several factors, including diminished glucagon secretion hindering the counter-regulatory response to low blood glucose and impaired renal and liver function that reduces drug clearance.¹ Other factors may include poor food intake and impaired cognitive function. The current American Diabetes Association (ADA) guidelines for treating diabetes mellitus in older adults recommend deintensifying glycemic goals². Previous studies have found that many older patients with complex medical problems and in poor health are frequently overtreated.³ A recent study sheds some new light on why providers may not be following these recommendations. ⁴

According to the ADA guidelines, the patient’s health status is the most important factor when selecting treatment goals. As a patient’s health status worsens, a reduced reliance on A1c as the primary means for determining glycemic control and treatment simplification are warranted. Treatment simplification has been documented to reduce the frequency and duration of hypoglycemia regardless of A1c goal.⁵  However, simply liberalizing A1c goals without deintensifying treatment does not significantly decrease the incidence of hypoglycemia in older adults.⁶

Oddly, provider behavior is often the opposite of the ADA recommendations, as they are more likely to relax A1c goals in healthy patients and intensify them when the patient has complex medical and social problems. In a recent study conducted at Johns Hopkins University, the investigators surveyed physicians who practiced general medicine, gerontology, and endocrinology. They gave each participant three case archetypes to review and asked them to make treatment recommendations. In all three cases, the patient was more than 65 years old, had type 2 diabetes, and was taking either a sulfonylurea or insulin therapy. They asked several questions for each case to determine if they would deintensify or switch the patient’s medication regimen and what A1c goal they would assign. The three cases were different in important ways.  In the first case, the patient was in good health, and the A1c was 6.3%.  The second case had complex health problems and an A1c of 7.3%.  The patient in the third case was in poor health and had an A1c of 7.7%.  The participants were then asked a series of follow-up questions as the medical and social circumstances in each case became progressively more complex with an increasing number of hypoglycemia risk factors. The results showed that the respondents were twice as likely to deintensify or switch therapy in healthier patients. Moreover, nearly half of the participants selected goals that were more intensive than recommended based on the patient’s health status.

There may be several reasons why prescribers fail to deintensify therapy in older adults. In some cases, the clinician may believe the risk of diabetes complications outweighs the risk of hypoglycemia. This may be the reason why some clinicians actually intensify treatments in patients with complex health problems. In other cases, the patient may resist changes in their medication regimen.⁷ Both clinicians and patients may be fearful that deintensification may lead to an increase in adverse events.  Lastly, clinicians may be simply stuck in a routine and reluctant to “rock the boat” (so-called clinical inertia).

To deintensify treatment in older adults, there are three tactics to consider: 1) reducing the patient’s glycemic goals, 2) simplifying the regimen, and 3) reducing doses. The ADA stages its recommendations based on the patient’s health status/characteristics: healthy, complex, very complex, and end-of-life. It is worth noting that the American Association of Clinical Endocrinology makes no recommendations for deintensification in older adults.

Sulfonylureas and insulin are far more likely than other treatment options to cause severe hypoglycemia. In older adults, the recommendations shift focus from a reliance on A1c as the primary indicator of “good control” and instead use lack of symptoms and episodes of hypoglycemia as the indicators.^8,9

When determining the appropriateness of therapeutic changes, mortality and morbidity benefits are crucial determinates. In terms of mortality, deprescribing is unlikely to increase mortality — some evidence suggests that deprescribing may reduce mortality, but other studies found no effect.⁹ Morbidity is perhaps a better indicator of the therapeutic benefits of deprescribing. Regimen simplification and discontinuing high-risk medications (like sulfonylureas and insulin) significantly reduce the risk of hypoglycemia, which may lead to falls and has been linked to worsening cognitive dysfunction.^3,11

As the population ages and the number of older adults living with diabetes grows, addressing the ways to improve quality of life without reducing its length is important to consider when making therapeutic decisions. Pharmacists can play an important role. In a recent study, a pharmacist-led deprescribing program implemented in an integrated health system decreased the incidence of hypoglycemia by over 50% when compared to usual care (1.5% vs 3.1%; adjusted OR= 0.42).¹²  In addition, all-cause mortality was significantly lower in the pharmacist deprescribing group (2.3% vs 5.6%; adjusted OR = 0.35).

While glycemic control is critically important in achieving optimal health outcomes, as patients with diabetes age, there needs to be a shift toward more relaxed goals and deprescribing medications that increase the risk for hypoglycemia.  Many clinicians fail to deintensify treatment in older adults in poor health with multiple co-morbidities.  Increasing awareness of the research in this area can help improve therapeutic decisions and health outcomes.

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