'Striking Paradox' of Misaligned Diabetes Treatment Could Harm

Marlene Busko

February 19, 2020

Older patients with diabetes and multiple comorbidities were more likely to be treated to a lower A1c level with insulin — exposing them to the risk of hypoglycemia — whereas younger healthier patients who could benefit from more aggressive therapy had worse glycemic control, in a new study based on US insurance claims.

The findings showed that "patients who are treated intensively are those who are most likely to be harmed by it," but those “who would benefit from more intensive treatment are not receiving the basic care that they need," lead author Rozalina G. McCoy, MD, an endocrinologist at the Mayo Clinic, Rochester, Minnesota, summarized in a press statement.

"The paradox and misalignment of treatment intensity with patients' needs are really striking," she noted.

"Patients who are older or who have serious health conditions are at high risk for experiencing hypoglycemia, which, for them, is likely to be much more dangerous than a slightly elevated blood sugar level," McCoy continued.

But "the benefits of intensive treatment usually take many years, even decades, to realize...so many [older] patients may be treated intensively and risk hypoglycemia for no real benefit to them."

On the other hand, younger healthier patients are less likely to experience severe hypoglycemia and are most likely to achieve meaningful long-term health improvements with intensive diabetes therapy. So, McCoy said, they "should be treated more aggressively, meaning that we should not shy away from using insulin or multiple medications to lower the A1c."

The study was published online February 19 in BMJ Open Diabetes Research & Care.

Diabetes Overtreatment, Undertreatment Paradox

Earlier research has reported high rates of potential overtreatment in older adults who have type 2 diabetes and serious comorbidities.

To investigate this further, McCoy and colleagues analyzed data from Optum Labs Data Warehouse from 194,157 adults with type 2 diabetes covered by commercial health insurance or Medicare Advantage from 2014 through 2016.

They identified the presence of 16 comorbidities that, according to clinical practice guidelines by the American Diabetes Association, American Geriatrics Society, and US Department of Veterans Affairs/Department of Defense, warrant a relaxation of glycemic targets because they are associated with greater hypoglycemia risk, shorter life, functional impairment, or frailty.

These guidelines and those by the UK National Institute for Health and Care Excellence further advise caution in using insulin and sulfonylureas to treat older and clinically complex patients to avoid hypoglycemia.

The analysis showed almost half of patients (45.2%) had diabetes-concordant comorbidities — retinopathy, neuropathy, heart failure, myocardial infarction, stroke, chronic kidney disease, or hypertension — that share common treatment strategies with diabetes.

Another 30.6% of patients had both diabetes concordant and discordant comorbidities — chronic obstructive pulmonary disease, liver disease, falls, incontinence, arthritis, or depression.

Few patients (2.7%) only had diabetes-discordant comorbidities.

And 13.0% of patients had advanced comorbidities — end-stage renal disease, dementia, and cancer — which may take precedence over all other disease management.

The youngest patients, age 18 to 44, had the highest mean A1c levels, at 7.7%, and the oldest patients, age ≥ 75, had the lowest mean A1c levels, at 6.9%.

Patients with none of the comorbidities had the highest mean A1c levels, at 7.4%, and those with advanced comorbidities had the lowest mean A1c levels, at 7.0%.

Physicians Need to Overcome Therapeutic Inertia, Individualize Treatment

"Patients least likely to benefit from intensive glycemic control and most likely to experience hypoglycemia with insulin therapy [ie, older patients with multiple comorbidities] "were most likely to achieve low [A1c] levels and to be treated with insulin to achieve them," the authors reiterate.

In contrast, younger patients and patients with few comorbidities were least likely to have low glycemic levels or be treated with insulin at higher A1c levels.

"Importantly, these [A1c] levels reflect [A1c] levels achieved by the patient, not necessarily A1c levels pursued by the clinician," the authors note.

The study shows that clinicians need to overcome "therapeutic inertia" — failure to recognize an appropriate time to modify treatment — in diabetes management, McCoy added.

"We have a great opportunity to simplify and de-intensify the treatment regimens of our more elderly patients," she said, "which would reduce their risk of hypoglycemia and treatment burden without spilling over into hyperglycemia."

"At the same time, we need to better engage younger, healthier patients, work with them to identify barriers to diabetes management, and support them to improve their glycemic control."

"Most importantly, clinicians should continue to engage their patients in shared and informed decision-making, weighing the risks and benefits of glucose-lowering treatment regimens in the specific context of each patient, carefully considering the patient's comorbidity burden, age, and goals and preferences for care," the authors conclude.

The research was supported by the National Institute of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Agency for Healthcare Research and Quality, and AARP through a Quality Measure Innovation Grant in collaboration with OptumLabs and the National Quality Forum Measure Incubator. The authors have reported no relevant financial relationships.

BMJ Open Diab Res Care. 2020;8:e001007. Full text

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