Deprescribing Antidiabetic Drugs: The Crowdsourced Opinion

Charles P. Vega, MD

Disclosures

October 16, 2019

The potential challenges in deprescribing antidiabetic drugs in older adults were the focus of a recent case I presented on Medscape. The question I posed was whether to stop or switch any of the patient's diabetes drugs.

To recap: The patient was an obese, 85-year-old woman with type 2 diabetes who didn't exercise or follow a healthy diet. She was experiencing regular episodes of mild hypoglycemia on her regimen of metformin and glipizide. As a first step, I recommended deprescribing the sulfonylurea glipizide.

With thoughtful and insightful comments, most readers were in agreement with this approach. As one reader pointed out, this case illustrates something of a therapeutic gray area in type 2 diabetes, and the best management for this patient can't be determined with certainty based on limited information. Several responses suggested engaging this patient and her family in motivational interviewing to optimize her care. And the silver lining might be that by increasing engagement in her plan of care, the patient may be more adherent to therapy and even willing to make other healthy lifestyle changes. It is possible!

Discontinuing the glipizide was the most popular option among those who participated in the discussion. If it is not deprescribed, we have to consider the long-term safety of this drug. Is this patient's intermittent hypoglycemia likely to get better or worse over time? She currently claims to eat small portion sizes, and older adults tend to eat less over time. If this occurs, the mild hypoglycemia she has experienced could evolve into an emergency. Even with a dose reduction, her future with a sulfonylurea will be dangerous.

There was some good discussion about potential replacements for her glipizide. Newer agents were preferred, and several participants believed that an SGLT2 inhibitor or glucagon-like peptide-1 receptor agonist would be a good choice because of their proven cardiovascular benefits in patients at high risk for a cardiovascular event. Some commenters also supported DPP-4 inhibitors, which I do not use frequently in my practice due to a combination of a fairly weak effect on A1c, no proven cardiovascular benefit, and high cost. But I teach our students that DPP-4 inhibitors are like the Golden Retrievers of antidiabetes drugs; they work well with other agents and present few complications. Patients like them even if they don't seem to accomplish a lot.

Finally, I would be cautious about reducing her statin dose. Statin use among the elderly is controversial, but there is no doubt that this patient is in a very high-risk cardiovascular category due to her history of coronary artery disease and multiple risk factors. A meta-analysis of statin trial participants published early in 2019 demonstrated that more intense statins can still be beneficial in the prevention of vascular events and vascular death among patients over 75 years of age. The effect of statins in raising blood glucose is modest, so I would be hesitant to change her high-dose statin without a more compelling reason to do so.

As with most patients, the best course of therapy in this case is not clear-cut. But applying clinical logic and incorporating the values of the patient are sure to yield the best outcomes for her in the short- and longer term.

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