Reducing Diabetes Meds Uncommon After Hypoglycemic Emergency

Miriam E. Tucker

November 02, 2021

Even after a hypoglycemic emergency, deintensification of insulin or sulfonylureas occurred in less than half of older adults with diabetes during a 10-year period, new research finds.

However, rates of deintensification within 100 days of a hypoglycemic-related emergency department visit or hospitalization among older patients with diabetes did increase over the decade, from 2007 to 2017.

But the rate stubbornly remained less than 50% and should be higher according to guidelines, say Anastasia-Stefania Alexopoulos, MBBS, of the Division of Endocrinology at Duke University, Durham, North Carolina, and colleagues.

"Older adults with diabetes who are admitted for hypoglycemia are at exceedingly high risk of future events...We should continue to consider and prioritize individual risk factors for severe hypoglycemia...which may include history of such events as well as the ongoing risk for hypoglycemia conferred by selection of diabetes regimen," Alexopoulos, who is also a staff endocrinologist at the Durham Veterans Affairs Medical Center, told Medscape Medical News.

She added that population-level risks of recurrent hypoglycemia could be further reduced with emergency department or hospital-based initiatives for patients who present to the hospital "to notify providers in real-time about opportunities for guideline-based deintensification of hypoglycemia-inducing medications."

Alexopoulos and colleagues have reported their findings in a new article published online November 2 in JAMA Network Open.

Guidelines by the American Diabetes Association advise the following:

  • In older adults with type 2 diabetes at increased risk of hypoglycemia, medication classes with low risk of hypoglycemia are preferred.

  • Overtreatment of diabetes is common in older adults and should be avoided.

  • Deintensification (or simplification) of complex regimens is recommended to reduce the risk of hypoglycemia and polypharmacy, if it can be achieved within the individualized A1c target.

  • Consider costs of care and insurance coverage rules when developing treatment plans to reduce risk of cost-related nonadherence.

"We Were Surprised to See How Low Deintensification Rates Were"

The retrospective cohort study included a random nationwide sample of fee-for-service US Medicare beneficiaries aged 65 and older with part A (inpatient services), part B (outpatient care), and part D (outpatient prescription drug) coverage between January 1, 2007, and December 31, 2017.

The study population was 76,278 individuals who had a hypoglycemia-related emergency department visit or hospitalization while taking sulfonylureas and/or insulin.  

Treatment deintensification was defined as a decrease in sulfonylurea dose, a change from long-acting to short-acting sulfonylurea (glipizide), discontinuation of sulfonylurea, or discontinuation of insulin, based on pharmacy dispensing claims, within 100 days after the hypoglycemia incident. Changes in insulin dosing couldn't be captured from the claims data.

A total of 32,074 episodes (30.2%) occurred among those receiving sulfonylurea only, 60,350 (56.8%) among those treated with insulin only, and 13,869 (13.0%) of those taking both sulfonylurea and insulin.

The incidences of treatment deintensification were 48.1% among those receiving both sulfonylurea and insulin, 44.2% among those receiving sulfonylurea only, and 24.0% among those receiving insulin only.

"We expected to find generally low deintensification rates, based on data from other studies, but we were surprised to see how low the deintensification rates were after a severe hypoglycemia event," Alexopoulostold Medscape Medical News.  

Those rates did increase between 2007 and 2017, from 41.4% to 49.7% for the sulfonylurea-only group (P trend < .001), from 21.3% to 25.9% for insulin only (P trend < .001), and from 45.9% to 49.6% for those taking both (P trend = .005).

Yet, the overall rate remained below 50% even in 2017.

Individuals who were receiving low-income subsidies were significantly less likely than those who weren't to receive treatment deintensification in all three treatment groups, with odds ratios of 0.74, 0.71, and 0.72 for sulfonylurea only, insulin only, and sulfonylurea and insulin, respectively.  

Clinical factors significantly associated with greater odds of treatment deintensification in all three groups included frailty (defined as 40% or greater probability of needing assistance with activities of daily living), with odds ratios of 1.38, 1.31, and 1.50 for sulfonylurea only, insulin only, and both, respectively, and chronic kidney disease (1.34,1.26, and 1.34, respectively).

Researchers Unable to Examine Discontinuation of Different Insulins

The fact that the authors were unable to assess adjustments in insulin dose, and by insulin type, was a study limitation, they note.

"Discontinuation of short- and/or long-acting insulins were included in our definition of insulin deintensification. For individuals on both short- and long-acting insulin, it is likely that deintensification of short-acting insulin would occur first, to minimize hypoglycemia risk," Alexopoulos said.

"However, we cannot be sure since we did not examine deintensification of short- vs long-acting insulin separately. It would be interesting to explore specific patterns of insulin deintensification in future work, as well as changes in insulin doses with data that may provide more detail on those factors," she added.

She also noted: "Given the lower cost of sulfonylureas and insulin compared to other newer diabetes medications, it is possible that cost could be playing a role in deintensification decisions...our research team is currently developing a new study to specifically explore disparities in potential overtreatment of type 2 diabetes in older adults."

The study was supported by grants from the Centers for Disease Control and Prevention, the National Center for Advancing Translational Sciences, the National Institute of Allergy and Infectious Diseases, the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institutes of Health, the National Institute on Aging, and the US Department of Veterans Affairs. Alexopoulos has reported no industry funding. Disclosures for the other authors are listed with the article.

JAMA Netw Open. Published online November 2, 2021. Full text

Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape, with other work appearing in The Washington Post, NPR's Shots blog, and Diabetes Forecast magazine. She is on Twitter: @MiriamETucker.

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