Diabetes Medications: Should You Deprescribe Them in the Elderly?

Plugging the Gap in Diabetes Treatment Guidelines

Linda Brookes, MSc

Disclosures

December 27, 2017

Deprescribing Antihyperglycemics

Researchers at the deprescribing project based at the Bruyère Research Institute in Ottawa, Canada, have just published another deprescribing algorithm, this one focused on antihyperglycemic agents.[1] The aims is to guide healthcare professionals in stopping, switching, or lowering the dose of these drugs in patients at risk for hypoglycemia or other antihyperglycemic adverse effects or in whom the drug's benefit is uncertain due to frailty, dementia, or limited life expectancy. Lead author Barbara Farrell, PharmD, spoke with Medscape about the guideline and its recommendations.

Recent studies in the United States and Canada have shown that many older patients with diabetes are still being treated to A1c <7%.

"The intensity of glycemic control needed in older people is quite controversial, with different diabetes guidelines recommending different targets," explained Dr Farrell. Around 5 years ago, treatment guidelines, which had previously favored a glycated hemoglobin (A1c) target of <7% (53 mmol/mol) for most people, set less stringent targets for the elderly (age ≥65 years). Many current international and national guidelines now recommend approximate treatment goals of <7.5% (58 mmol/mol) in healthy older adults and <8.5% (69 mmol/mol) in the very frail elderly.[2,3,4,5,6] These changes in targets result from clinical trials showing that compared with conventional glycemic control, intensive control did not significantly reduce all-cause or cardiovascular mortality.[7] It did, however, increase the risk for hypoglycemia and serious adverse events,[8,9] especially in elderly patients.[10,11] Hypoglycemia is associated with cardiovascular events, cognitive impairment, fractures, death, and reduced quality of life.[12,13] It is a leading cause of emergency department visits in older adults in the United States.[14] Hospitalization for hypoglycemia is associated with a poor prognosis.[15]

Need for New Guidelines

Despite the new guidelines and "Choosing Wisely" campaigns specifically cautioning against intensive glycemic control in the elderly,[16,17] recent studies in the United States and Canada have shown that many older patients with diabetes are still being treated to A1c <7%.[18,19,20,21,22]

"In the United States and Canada, the concept of treating to specific number targets has been very entrenched in the medical communities and among the public, so it is a difficult thing to change," Dr Farrell stressed. "The diabetes guidelines all talk about how to start these drugs, and some of them discuss how to adjust doses for kidney function or for age, but they don't specifically address how to reduce a dose or how often to monitor while you are reducing it. That is why we developed the deprescribing guideline, to fill that gap," Dr Farrell explained. "For patients with low blood sugar, in particular the frail elderly, we wanted to be able to provide guidance to prescribers about when it might be appropriate to start reducing doses or just stopping some of those medications that can contribute to low blood sugar. What we are most concerned about is ensuring that people are switched off those medications and either continue on their remaining medications or with safer ones substituted. We need to be looking at safety as an increasing priority over the potential long-term benefits of keeping blood sugar very low. It is challenging because every person is different in terms of identifying when the balance of risk of medication versus benefit changes."

The guideline does not set specific glycemic targets, referring to Canadian Diabetes Association and other, similar guidelines that address the need for less stringent targets in the elderly.

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