Lifestyle Med Experts Tell How to Deprescribe Diabetes Meds

Marlene Busko

May 01, 2023

Nine lifestyle medicine practitioners describe how they safely and effectively deprescribe glucose-lowering medications after patients demonstrate a reduced need for such medications following lifestyle changes.

The report by Michael D. Bradley, PharmD, and colleagues was recently published as a feature article in Clinical Diabetes.

"Lifestyle medicine uses an evidence-based lifestyle therapeutic approach to treat lifestyle-related chronic disease," they explain, and it includes "a whole-food, predominantly plant-based eating plan, regular physical activity, restorative sleep, stress management, avoidance of risky substances, and positive social connection."

"Medication deprescribing," senior author Micaela C. Karlsen, PhD, told Medscape Medical News in an email, "is a planned and supervised process of dose reduction or discontinuation of a medication that may be causing harm, or no longer providing benefit to a patient." 

According to the authors, this article "is the first account published of the medication de-escalation methods used by lifestyle medicine providers when patients demonstrate a decreased need for pharmacotherapy." It "supports the feasibility of de-escalating glucose-lowering medications in this context and provides pilot data on protocols from individual practitioners experienced in deprescribing glucose-lowering medications."  

The study was not designed to cover deprescribing glucose-lowering medications following weight loss and diabetes remission after bariatric surgery.

"A key takeaway [from the current study] for general practitioners and endocrinologists is that while deprescribing is already known to be beneficial to reduce polypharmacy, it may be appropriate following lifestyle interventions," said Karlsen, who is senior director of the American College of Lifestyle Medicine (ACLM) in Chesterfield, Maryland.

"The protocols presented [in the article] can serve as a model for how to do so," she continued.

The American Diabetes Association and the American Association of Clinical Endocrinology (AACE) recommend lifestyle optimization as part of medical care for type 2 diabetes.

According to the ACLM, "remission of type 2 diabetes should be a clinical goal and may be achieved with a whole-food, plant-based dietary pattern coupled with moderate exercise," the researchers note.

"Remission," they specify, "can be defined as attainment of an A1c < 6.5% for at least 3 months with no surgery, devices, or active pharmacologic therapy for the specific purpose of lowering blood glucose."

In ACLM's recent expert consensus statement on dietary interventions for type 2 diabetes remission, which was also endorsed by AACE, supported by the Academy of Nutrition and Dietetics, and co-sponsored by the Endocrine Society, panel members agreed that remission is a realistic and achievable goal for some adults with type 2 diabetes, and a high-intensity dietary intervention can result in remission, Karlsen said.  

To avoid hypoglycemia when deprescribing antiglycemic drugs, medications known to cause hypoglycemia — notably sulfonylurea and insulin — are often deprescribed first, she noted.

"Our biggest hope," she said, "is that [type 2 diabetes] remission may come to the forefront as a clinical goal in treatment and that other organizations will more strongly emphasize lifestyle in standards of care."

"We hope that clinicians reading this paper will be made aware that de-escalation of glucose-lowering medications is feasible, is a desirable outcome, and can be necessary in a lifestyle medicine context," she added.

Further research is needed to prospectively track the likelihood of type 2 diabetes remission, factors that predict successful remission, and decision-making protocols followed by practitioners, Karlsen said.

Deprescribing Antiglycemic Meds in Lifestyle Medicine

Researchers at the Bruyère Research Institute, in Ottawa, Ontario, and Université de Montréal, Quebec, Canada, provide algorithms for deprescribing antihyperglycemic medications specifically for older individuals.  

In the current study, the authors conducted individual, 30-minute to 1-hour interviews with nine lifestyle medicine practitioners to document their protocols for deprescribing glucose-lowering medications after lifestyle interventions with a goal of potential type 2 diabetes remission.

Three practitioners reported medication deprescribing in an intensive therapeutic lifestyle program (longer, more frequent treatment with greater monitoring). The others provide deprescribing in a nonintensive program (similar to primary care practice) or both.

Deprescribing is necessary when using intensive therapeutic lifestyle change, as substantial and rapid drops in glucose levels aren't adjusted for, the authors note.

Most practitioners work with a team of allied healthcare providers.

During the deprescribing process, most protocols require that patients get a basic or comprehensive metabolic panel of blood tests, with variations in laboratory tests for A1c, C-peptide, and renal function.

Most practitioners recommend a target blood glucose < 120 mg/dL for further deprescribing.

Currently, there is no clinical guidance for use of continuous glucose monitoring (CGM) during medication de-escalation, the authors note.

Most practitioners reported they consider patient expenses associated with CGM and third-party payor coverage in their decision-making.

Most practitioners prefer to deprescribe sulfonylureas, insulin, and other medications known to cause hypoglycemia first.

Conversely, most prefer to defer deprescribing medications that have demonstrated cardiovascular and/or renal benefits (ie, glucagon-like peptide 1 [GLP-1] receptor agonists and sodium-glucose cotransporter 2 inhibitors), as well as those with a less severe adverse effect profile (ie, metformin and GLP-1 receptor agonists) until after other medications are deprescribed.  

The study was funded by the Ardmore Institute of Health. The authors have reported no relevant financial relationships.

Clin Diabetes. Published online April 14, 2023. Article 

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