Progress on T2D 'Creates Need for De-prescribing Protocols'

Liam Davenport

November 04, 2019

LONDON — The revolution in the management of type 2 diabetes that has seen the perception of the disease shift from one of inexorable progression to potential remission or reversal means that careful consideration will be needed into how to manage taking patients off their medications, warns a UK general practitioner.

Dr Farhan Rabbani, medical director, The Diabetes Reversal Company, and a GP partner and GP trainer at Wallington Medical Centre, in London, said that recent trials have shown that it is possible to help patients to reverse their disease.

While this means that they could stop some or all of their medications, he told Diabetes Professional Care 2019 that there are no guidelines on how to 'de-prescribe' patients and, while he and his colleagues have developed a common sense protocol, much more work is needed.

De-prescribing

Dr Rabbani began by noting that "every guideline we have is about putting people on medication", whereas his talk was about "taking people off medication".

He said that "it's a very innovative area to be in" and, as there are no hard and fast rules about de-prescribing in diabetes, he would recount his experiences at his practice.

For him, the notion of de-prescribing forms part of lifestyle medicine, in which lifestyle interventions are used to treat and, ideally, reverse chronic diseases.

While the approach has been followed in the USA for around 30 years, it is just beginning to be adopted in the UK.

Dr Rabbani said that, "when you think about it, it makes sense", adding: "When you've got a disease that's caused by someone's lifestyle, why don't we treat the underlying cause, which is their lifestyle?"

That begs the question, however: "How do you do that?"

He said that "everyone has got a different opinion" about what for example, constitutes the ideal diet, but he believes that the best lifestyle intervention is "whatever the patient can follow long-term".

"It's not about what's right for the next 3 months or 6 months, it's what can they see themselves doing in the next 3 years, at the very least."

The next question is then: "What to do with the medication?"

Dr Rabbani pointed out that the DiRECT trial, (Diabetes Remission Clinical Trial), which had so much success in reversing diabetes with a calorie-restricted diet followed by gradual reintroduction of foods, required patients to stop all medications on "day one".

He said that it is "fine" in a clinical trial setting, where there is "intensive support", but that may not be "the safest thing to do" in the real world.

To achieve de-prescribing in their practice, Dr Rabbani and colleagues have developed a protocol that relies on a phased approach, in which medications are taken off one by one.

He underlined that the protocol, which is available on request to healthcare professionals, is "something we've developed ourselves" and is not nationally validated "because it hasn't been looked at nationally".

He described the idea of taking diabetes patients off mediation as a "symptom" of the journey that has been made in tackling chronic diseases.

"Five or 10 years ago, we didn't talk about reversing or remission of type 2 diabetes; it's become more of a recent thing since publications like DiRECT have come out."

'Reversing Guidelines'

When it comes to how patients are de-prescribed in practice, Dr Rabbani said they have tried to be "as straightforward as possible".

He explained that National Institute for Health and Care Excellence (NICE) guidelines state that you start with "drug A and then you go to drug B, then you go to drug C".

"So what we do is we do NICE guidelines in reverse. We take off drug C, we then take off drug B, and drug A."

While he admitted that it sounds "a bit too straightforward", he said that "it does work and there is some common sense to it".

This, Dr Rabbani said, is with the caveat in diabetes that the oral sulphonylureas can induce hypoglycaemia.

Consequently, if a patient is taking metformin alone, he and his colleagues will simply stop the drug, but if the patient is taking metformin and a sulphonylurea or even triple medication, they usually take the sulphonylurea off first.

Opening up the discussion to the floor, an audience member asked whether de-prescribing increases the risk of losing patients to follow-up.

Dr Rabbani said that, in their practice, they leave type 2 diabetes patients on the diabetes register, even if they have normal blood glucose levels and are not taking any medications, and so they continue to have their annual check-up.

He added that if a patient with a long-standing condition such as type 2 diabetes sees such a significant improvement in their condition that they are able to stop taking medication, "there is less of a risk of them not being engaged in the future".

Thresholds

Another member of the audience asked, if Dr Rabbani's practice is using the NICE guidelines in reverse, what would they do with a patient who is on the threshold for stopping a drug.

He explained that, if a patient has an HbA1c level of 48 mmol/mol, would they not then be at risk of seeing their blood glucose level going a lot higher if their drug treatment were stopped? Consequently, should a lower threshold be used?

Dr Rabbani replied that the answer is that "you have to look at the patient as a whole", particularly in terms of their other, non-diabetes medications, such as statins.

However, if a patient had got to that HbA1c level by losing a lot of weight and "feels a lot healthier", then their doctor should also consider reducing their antihypertensive and anti-cholesterol medications.

"It's actually quite complex, because all these symptoms are interlinked and the underlying cause is the same."

This, he believes, will eventually require the development of an algorithm for de-escalating therapy, but thinks that is "a few years away".

The concept, Dr Rabbani continued, sits in contrast to that of the "medication review", which is typically about checking drug interactions and compliance, "but there's literally nothing out there that's for taking people off medications".

Continuing on the theme of adopting a holistic approach to the patient, he said that factors such as who does the food shopping in the patient's life, or whether friends or relatives bring them treats, need to be addressed.

In the case of one patient Rabbani treated, he said that it was necessary to get the "buy in" of his wife to make a difference through lifestyle changes, as she did all the shopping and made all the meals.

Otherwise, "he hasn't really got a chance".

In addition, his grandchildren brought him a box of chocolates every time they saw him during the weekend, "so we had to stop that".

The consequence was he lost weight and saw his HbA1c drop from 90 mmol/mol to 54 mmol/mol, allowing him to be discharged from the diabetes clinic.

His arthritic knee also improved, so he was able to start walking again, "and the best thing about this whole story" was that he inspired his family to lose weight, and one of his daughters, who was diabetic, is now in remission.

Rabbani is Medical Director of The Diabetes Reversal Company.

No funding declared.

Diabetes Professional Care 2019: Panel: Deprescribing for cost saving in diabetes care. Presented 30th October.

Editor's Note, 5th November 2019: This article was updated to include contact details for Dr Rabbani's team. 

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