Overtreatment Common Among Older People With Diabetes

Miriam E Tucker

January 24, 2018

Type 2 diabetes is treated too aggressively in a substantial proportion of older people, with probable harmful consequences, a new analysis suggests.

Data from a Dutch cohort were published online January 24 in Diabetes, Obesity and Metabolism by Huberta E Hart, MD, of the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands, and colleagues.

The benefits of tight glycemic control haven't been proven in older adults with a long-duration of type 2 diabetes and vascular complications. Moreover, for many with shorter life expectancy, any benefit could be outweighed by the risk of hypoglycemia.

For that reason, guidelines from several professional societies have advised less-strict glycemic targets for older adults. 

Nonetheless, the new study showed that about 20% of 319 adults with type 2 diabetes aged 70 and older were overtreated in five primary care practices, based on Dutch guidelines for individualized HbA1c targets.

And this was despite the fact that many had complications, comorbidities, and were taking medications that can cause hypoglycemia. In addition, treatments were not de-intensified even after reports of hypoglycemia or falls.

"Although the number of patients included in this study was small, the results give a clear signal that overtreatment in older patients with type 2 diabetes is a real problem," Dr Hart and colleagues write.

The patients in this study would have been considered overtreated according to guidelines by the American Diabetes Association and European Association for the Study of Diabetes as well, they note. 

"Care professionals should abandon the 'one size fits all' approach and realize the possible benefits of de-intensifying blood glucose-lowering treatment," the authors stress.

To prevent overtreatment, they advise that guidelines include a lower HbA1c limit, and that diabetes quality indicators "should not be based on population-based mean values," because these averages completely overlook under- and overtreatment.

Overtreatment Quite Common, Often Causes Harm

In their study, Dr Hart and colleagues assessed the level of personalized diabetes treatment for older patients in primary care. They note that 85% of people with type 2 diabetes are treated by general practitioners in The Netherlands.

Based on Dutch College of General Practitioners 2013 guidelines, they used the following targets for those aged 70 and over: HbA1c ≤ 7% (53 mmol/mol) for patients given lifestyle advice only or metformin monotherapy; HbA1c ≤ 7.5% (58 mmol/mol) for patients using other glucose-lowering drugs in addition to metformin with a diabetes duration < 10 years; and HbA1c ≤ 8.0% (64 mmol/mol) for patients with a diabetes duration ≥ 10 years.

They analyzed the primary care electronic records of 1002 patients with type 2 diabetes, including 319 patients aged 70 or older.

"On target," "overtreated," and "undertreated" were defined according to values that met, or were above or below, the recommended targets.

Researchers calculated that of the 319 patients aged 70 or older, 165 patients — around one in two — should have a target HbA1c > 7% according to the guidelines.

Overall, 64 patients were overtreated; that is, around 40% of the 165 patients, constituting 20% of all participants aged 70 or older.  

Many people who were overtreated had microvascular and macrovascular complications, comorbidities, used multiple medications, could be considered frail, and took medications that can cause hypoglycemia.

Indeed, hypoglycemia occurred in 20.3% of these patients, and almost 30% reported accidents involving falls.

Still, in some cases for well-informed patients who prefer to continue intensive glycemic control, "a shared decision could be to do so. From a medical point of view such a patient might be called overtreated, but in a person-centered diabetes care setting, this is acceptable," Dr Hart and colleagues point out.

However in general, "In older patients with longstanding diabetes and a complex treatment regimen, the risk–benefit ratio of stringent blood glucose treatment is doubtful," said Dr Hart.

"Physicians, follow the guidelines and dare to de-intensify the blood glucose lowering medication in a shared decision with your older patient with diabetes," she concluded.

The authors have reported no relevant financial relationships.

Diabetes Obes Metab. Published online January 24, 2018. Abstract

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