Meds Seldom Deintensified in Elderly Diabetics: VA Study

Veronica Hackethal, MD

October 30, 2015

Only about one-quarter of older diabetic patients who have low blood pressure or low HbA1c levels due to medication have their treatment deintensified, according to a Veterans Administration (VA) study published online on October 26, 2015 in JAMA Internal Medicine. The findings point to the need for practice guidelines and performance measures that emphasize medication deintensification and prevention of overtreatment, researchers say.

"We found that only one in four of nearly 400,000 older patients who could have been eligible to ease up on their multiple blood-pressure or blood sugar medicines actually had their dosage changed," commented first author Jeremy Sussman, MD, of the VA Center for Clinical Management Research in Ann Arbor, Michigan.

Older people may experience more side effects from their medications, while they may reap fewer benefits from them, Dr Sussman noted. "For patients with diabetes, in particular, we now know that treating people's blood pressure or blood sugar with too many medicines can be dangerous."

Patients at risk, he explained, include those with very low blood pressure (such as systolic BP < 120 mm Hg) or very low blood glucose (HbA1c < 6.0%). People who are at greatest risk and those less likely to benefit from tight control include those on many medicines, the elderly, and those with a history of side effects to medicines.

Clinical-practice guidelines and quality-of-care initiatives have generally focused on intensification of therapy and treating to certain targets. The tide has gradually begun to turn, however, with some organizations recommending less aggressive treatment in older patients or those with limited life expectancies.

The Choosing Wisely campaign by the American Board of Internal Medicine foundation recommends avoiding the use of medication to reach a target HbA1c < 7.5% in most adults age 65 years or older. In addition, American Diabetes Association guidelines say that an HbA1c between 7.5% and 8.0% is acceptable in older patients. Guidelines developed by the Eighth Joint National Committee recommend treating systolic blood pressure in older patients to a goal of <150 mm Hg, rather than the former goal of <140 mm Hg.

The retrospective cohort study included data on 211,667 patients seen at VA primary-care clinics during 2012. Included patients were age 70 years or older, had type 1 or type 2 diabetes, were currently on antihypertensives other than ACE inhibitors or angiotensin receptor blockers, or were on antidiabetes medications other than metformin. Over 98% of participants were male, with a mean age of 78 years.

There were only weak associations between rates of deintensification and estimated life expectancy, blood pressure, and HbA1c.

Of patients with actively treated blood pressured (n=211,667), over 50% had blood pressure that was moderately low (systolic blood pressure [SBP] 120-129 mm Hg systolic, or diastolic blood pressure [DBP] <65 mm Hg), or very low (<120/65 mm Hg). Among 25,955 patients with moderately low pressure, 16.0% received deintensification. Among 81,226 patients with very low blood pressure, 18.8% had medication deintensification.

Among patients with very low blood pressure who did not receive medication deintensification, just 0.2% had elevated blood pressure (≥ 140/90 mm Hg) at 6-month follow-up, while 28.1% had continued low blood pressure, and 61.6% had no documented measurement.

Of patients with actively treated diabetes (n=179,991), over 20% developed HbA1c levels that were moderately low (6.0%–6.4%), or very low (<6.0%). Among 23,769 patients with moderately low HbA1c levels, 20.9% received deintensification. Among 12,917 patients with very low HbA1c levels, 27.0% received deintensification.

Among patients with very low HbA1c levels who did not receive deintensification, less than 0.8% had elevated HbA1c of ≥7.5%, 16.9% had continued low HbA1c at 6 months, and 79.8% had no documented HbA1c.

The lack of documented BP and HbA1c at follow-up suggests that providers may think that low values are not a problem in need of monitoring, the authors pointed out.

Quality-improvement efforts should create incentives aimed at improving both over- and undertreatment and encourage deintensificaiton when appropriate, according to the authors, who add that the VA has recently started such a program called the Hypoglycemia Safety Initiative.

Medication deintensification, though, can be a thorny issue. No specific recommendations exist for it. In addition, providers may fear that they will perform worse on quality-assurance measures designed to encourage tight control. Patients may also find the transition difficult.

In a related study, researchers at the VA and the University of Michigan looked at this issue by asking primary-care providers about their beliefs surrounding medication deintensification. Between October 2014 and December 2014, they conducted a random, national survey of primary-care providers at the VA. The survey also asked about the scenario of a 77-year-old man who was at risk for hypoglycemia and had an HbA1c of 6.5%, severe kidney disease, and was taking glipizide 10 mg twice daily.

The study had a response rate of 48.6% (53.0% women, 23.4% nurse practitioners, 7.8% physician assistants, and 68.8% physicians). About 38% of primary-care providers thought that the patient in the scenario would benefit from maintaining his HbA1c below 7.0%. Almost half (44.9%) would not worry about potential harm from tight control, and 42.2% were concerned that deintensification would result in unfavorable performance ratings, even though the VA has never adopted performance measures about targeting HbA1c levels <7.0%. About 23% worried about being vulnerable to malpractice if they decreased his medication.

"National guidelines that clarify when to deintensify medication use and balanced performance measures that incentivize appropriate intensification and deintensification could improve prescribing practices and prevent many adverse events in older patients with diabetes," concluded first author Tanner J Caverly, MD, MPH, of the Ann Arbor Veterans Affairs Center in Ann Arbor Michigan, and colleagues.

In a commentary, Enrico Mossello, MD, PhD, of the University of Florence, Italy, raises some caveats. Little research has been done on the outcomes of patients who receive deintensification, he writes. Moreover, creating incentives for deintensification could encourage avoidance of preventive strategies.

"Less is not always more, and we should not risk eliminating the benefits of therapy while attempting to lower the risk," writes Dr Mossello, who proposes a schema for antihypertensive and antidiabetic treatment strategies based on patient vulnerabilities.

Indicators are needed that identify vulnerable patients for whom less stringent targets could improve outcomes, he proposes. Some patients may need repeated risk-factor checks and/or comprehensive geriatric assessments. Finally, more clinical trials are needed to evaluate the effect of deintensification on specific vulnerable groups and to identify appropriate targets for treatment.

"Clinical performance measures coupling treatment deintensification with appropriate clinical assessments and monitoring seem reasonable to safely discontinue unnecessary and potentially harmful treatments while retaining the benefits of vascular prevention," Dr Mossello emphasizes. "This approach will be key to designing effective personalized prevention strategies for older vulnerable subjects."

Sussman and coauthors report no relevant financial relationships, as does Dr Mosello. Dr Caverly reports no relevant financial relationships; disclosures for the coauthors are listed in the paper.

JAMA Intern Med. Published online October 26, 2015. Sussman article, Caverly article, Editorial


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