Diabetes Medications: Should You Deprescribe Them in the Elderly?

Plugging the Gap in Diabetes Treatment Guidelines

Linda Brookes, MSc

Disclosures

December 27, 2017

Which Drugs to Stop?

"There was a particular worry about glyburide, the long-acting sulfonylurea that frequently causes hypoglycemia," Dr Farrell said. This usually happens because glyburide was started when patients were younger, and they have been taking it for many years, she explained. Switching glyburide to short- or long-acting gliclazide may reduce but will not eliminate the risk for hypoglycemia. Options other than a sulfonylurea should be considered.

"The other medication that can cause hypoglycemia is insulin, so cut back on the doses if the blood sugar is too low," Dr Farrell added. The highest risk is with neutral protamine Hagedorn (NPH) insulin, and the guideline advises switching NPH insulin or mixed insulin to insulin detemir or glargine to reduce nocturnal hypoglycemia.

The guideline also lists the antihyperglycemic medications with no or low risk for hypoglycemia (Table).

Table. Medications With Low or No Risk for Hypoglycemia

Drug Risk for Hypoglycemia
Alpha-glucosidase inhibitors No
Dipeptidyl peptidase-4 (DPP-4) inhibitors No
Glucagon-like peptide-1 (GLP-1) agonists No
Meglitinides (glinides) Yes (low risk)
Metformin No
Sodium-glucose linked transporter 2 (SGLT2) inhibitors No
Thiazolidinediones No
Data from Farrell B, et al.[1]

Tapering and Monitoring

"There is no evidence that one tapering approach is better than another," Dr Farrell noted. "With antihyperglycemic drugs, the only adverse effect from stopping is a rise in blood sugar that needs to be monitored. So if we have a patient who has very low blood sugar and no real problems with high blood sugar, we would just stop the sulfonylurea. If it's a low dose of insulin, we would stop that. In other cases, we might gradually reduce the dose, either because we think the patient would still benefit from having the drug even at a lower dose, or sometimes the patient is reluctant to just stop suddenly."

Frequency of monitoring the effects of deprescribing these drugs is highly individualized, depending on the patient's blood sugar levels and on the drugs that have been changed.

Frequency of monitoring the effects of deprescribing these drugs is highly individualized, depending on the patient's blood sugar levels and on the drugs that have been changed, Dr Farrell added. Monitoring need not be done daily unless insulin is being deprescribed. "If we are stopping glyburide or switching from glyburide to gliclazide, we might check once a week for a couple of weeks. Typically after most antihyperglycemic drugs are stopped, changes in blood glucose will be seen within 1 or 2 weeks," she said.

Other Causes of Hypoglycemia

Another unique aspect of the new guideline is the inclusion of different situations that can contribute to hypoglycemia, such as taking insulin and then not eating, taking other drugs that cause hyper- or hypoglycemia, or drug interactions with antihyperglycemic medication. "Sometimes we see that a patient has recently stopped a drug that causes hyperglycemia, but the dose of the diabetes drug has not been reduced," she explained. "For example, someone who is taking high-dose prednisone for a short period of time might experience a steep rise in blood sugar, and the dose of insulin or other antihyperglycemic drug is increased to cope with that. Then the prednisone is stopped, and the patient's blood sugar plummets. We might simply avoid the particular drug that causes that drug interaction, or we would probably consider lowering the dose of the antihyperglycemic drug."

Discussion With Patients and Families

One of the goals of the guideline is to encourage healthcare providers to discuss the rationale and benefits of deprescribing with patients and their families. "One of the biggest challenges is to explain the targets and the need to focus on safety versus not always focusing on preventing the long-term problems of diabetes," Dr Farrell said. "This can be especially difficult with older people who may have had diabetes for 30 years, and it may seem as though suddenly, out of the blue, we're not concerned about their blood sugar any longer. It is not an easy conversation to have, and it can be time-consuming," she acknowledged.

"When these medications are first prescribed to a newly diagnosed person, and targets are discussed, it would be helpful to also explain that when they are older or if they start having hypoglycemic episodes, these targets may change," she suggested. "We would establish that very intensive control is important in a younger person to prevent long-term complications but that as they get older we will revisit these targets, so they would know that modifying their targets as they get older is a normal part of the program."

Updating the Guidelines

Dr Farrell pointed out that the systematic review of evidence done for preparation of the new guideline[23] identified only two relevant studies of deprescribing antihyperglycemic agents.[24,25] Both studies concluded that the approach is safe and feasible, but the quality of the evidence was low, the guideline authors commented. "We would benefit from having more studies of deprescribing so that we can get a better understanding about whether there is an optimal approach to tapering, monitoring, and follow-up," Dr Farrell said. "Our eventual goal is that all prescribing guidelines will include deprescribing sections, so that specialists, family physicians, and all other healthcare professionals are on board with the approach."

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