Deintensification of Treatment With Sulfonylurea and Insulin After Severe Hypoglycemia Among Older Adults With Diabetes

Integrated approach to reducing polypharmacy in older people: exploring the role of oxidative stress and antioxidant potential therapy

Increased life expectancy, attributed to improved access to healthcare and drug development, has led to an increase in multimorbidity, a key contributor to polypharmacy. Polypharmacy is characterised by its association with a variety of adverse events in the older persons. The mechanisms involved in the development of age-related chronic diseases are largely unknown; however, altered redox homeostasis due to ageing is one of the main theories. In this context, the present review explores the development and interaction between different age-related diseases, mainly linked by oxidative stress. In addition, drug interactions in the treatment of various diseases are described, emphasising that the holistic management of older people and their pathologies should prevail over the individual treatment of each condition.

Crossing the deintensification chasm for older adults with diabetes

This editorial comments on the article by Haider et al.

Tertiary centre study highlights low inpatient deintensification and risks associated with adverse outcomes in frail people with diabetes

INTRODUCTION

The community deintensification rates in older people with diabetes are low and hospital admission presents an opportunity for medication review. We audited the inpatient assessment and deintensification rate in people with diabetes and frailty. We also identified factors associated with adverse inpatient outcomes.

METHODS

A retrospective review of electronic charts was conducted in all people with diabetes and clinical frailty score ≥6 who were discharged from the medical unit in 2022. Data on demographics, comorbidities and background glucose-lowering medications were collected.

RESULTS

Six-hundred-and-sixty-five people with diabetes and moderate/severe frailty were included in our analysis. For people with no HbA1c in the last six months preceding admission, only 9.0% had it assessed during inpatient. Deintensification rates were 19.1%. Factors that were associated with adverse inpatient outcomes included inpatient hypoglycaemia, non-White ethnicity, and being overtreated (HbA1c <7.0% [53 mmol/mol] with any glucose-lowering medication).

CONCLUSION

The assessment and deintensification rate in secondary care for people with diabetes and frailty is low. Inpatient hypoglycaemia, non-White ethnicity, and overtreatment are important factors in determining inpatient outcomes highlighting the importance of deintensification and the need for an evidence-based risk stratification tool.

De-escalating treatment indications for patients who achieve metabolic goals

INTRODUCTION

Robust evidence exists regarding initiation, intensification or modification of treatments. Recommendations to de-escalate therapy are lacking, specifically in diabetes. A successful treatment de-intensification reduces overtreatment, polypharmacy, and risk of adverse effects.

OBJECTIVE

To encompass current recommendations for deprescribing common drugs and create a consensus among health professionals.

METHODS

We reviewed four databases for deprescribing approaches published between 2010 and 2022. Articles were divided into different groups of drugs (for uric-acid, hypoglycemic, lipid-lowering, and psychotropic drugs).

RESULTS

Hypoglycemic agents: strategies were limited to newer agents and insulin regimens for elderly individuals. Reducing insulin was associated with 1.1% reduction of A1c over time. SGLT2i and GLP-1RAs dose reduction depends on adverse events. Lipid-lowering agents: studies show that patients with very low cholesterol have fewer cardiovascular events without associated increased risk. Antihypertensive agents: Younger patients, lower systolic blood pressure, and few comorbidities are ideal characteristics for discontinuation. Uric acid therapy: we found no recommendation for dose de-escalation. Poor treatment adherence is associated with episodes of gout and deforming arthritis in the long term.

CONCLUSION

Deprescribing hypoglycemic, statins, antihypertensives, and urate-lowering agents may be feasible in selected patients, but periodic surveillance is important. More evidence is necessary to support this decision entirely.

Reducing hypoglycemia from overtreatment of type 2 diabetes in older adults: The HypoPrevent study

BACKGROUND

Hypoglycemia from overtreatment is a serious but underrecognized complication among older adults with type 2 diabetes. However, diabetes treatment is seldom deintensified. We assessed the effectiveness of a Clinical Decision Support (CDS) tool and shared decision-making (SDM) in decreasing the number of patients at risk for hypoglycemia and reducing the impact of non-severe hypoglycemic events.

METHODS

HypoPrevent was a pre-post, single arm study at a five-site primary care practice. We identified at-risk patients (≥65 years-old, with type 2 diabetes, treated with insulin or sulfonylureas, and HbA1c  < 7.0%). During three clinic visits over 6 months, clinicians used the CDS tool and SDM to assess hypoglycemic risk, set individualized HbA1c goals, and adjust use of hypoglycemic agents. We assessed the number of patients setting individualized HbA1c goals or modifying medication use, changes in the population at risk for hypoglycemia, and changes in impact of non-severe hypoglycemic events using a validated patient-reported outcome tool (TRIM-HYPO).

RESULTS

We enrolled 94 patients (mean age-74; mean HbA1c (±SD)-6.36% ± 0.43), of whom 94% set an individualized HbA1c goal at either the baseline or first follow-up visit. Ninety patients completed the study. Insulin or sulfonylurea use was decreased or eliminated in 20%. An HbA1c level before and after goal setting was obtained in 53% (N = 50). Among these patients, the mean HbA1c increased 0.53% (p < 0.0001) and the number of patients at-risk decreased by 46% (p < 0.0001). Statistically significant reductions in the impact of hypoglycemia during daily activities occurred in both the total score and each functional domain of TRIM-HYPO.

CONCLUSIONS

In a population of older patients at risk for hypoglycemia, the use of a CDS tool and SDM reduced the population at risk and decreased the use of insulin and sulfonylureas. Using a patient-reported outcome tool, we demonstrated significant reductions in the impact of hypoglycemia on daily life.

Medication Prescribing for Type 2 Diabetes in the US Long-Term Care Setting: Observational Study

OBJECTIVES

To characterize prescribing of glucose-lowering medication annually and to quantify the annual frequency of hypoglycemia among residents in long-term care (LTC) facilities with type 2 diabetes mellitus (T2DM).

DESIGN

Serial cross-sectional study using a deidentified real-world database comprising electronic health records from LTC facilities.

SETTING AND PARTICIPANTS

Individuals eligible for this study were ≥65 years old with T2DM and recorded stay of ≥100 days at an LTC facility in the United States in any of 5 study years (2016-2020), excluding individuals receiving palliative or hospice care.

METHODS

Drug orders (prescriptions) for glucose-lowering medications for each LTC resident with T2DM in each calendar year were summarized by administration route (oral or injectable) and by drug class as ever-prescribed (ie, multiple prescriptions were included once), overall and stratified by age subgroup, <3 vs ≥3 comorbidities, and obesity status. We calculated the annual percentage of patients ever prescribed glucose-lowering medication each year, overall and by medication category, who experienced ≥1 hypoglycemic events.

RESULTS

Among 71,200 to 120,861 LTC residents with T2DM included each year from 2016 to 2020, 68% to 73% (depending on the year) were prescribed ≥1 glucose-lowering medications, including oral agents for 59% to 62% and injectable agents for 70% to 71%. Metformin was the most commonly prescribed oral agent, followed by sulfonylureas and dipeptidyl peptidase 4 inhibitors; basal plus prandial insulin was the most commonly prescribed injectable regimen. Prescribing patterns remained relatively consistent from 2016 to 2020, both overall and by patient subgroup. During each study year, 35% of LTC residents with T2DM experienced level 1 hypoglycemia (glucose ≥54 to <70 mg/dL), including 10% to 12% of those prescribed only oral agents and ≥44% of those prescribed injectable agents. Overall, 24% to 25% experienced level 2 hypoglycemia (glucose concentration <54 mg/dL).

CONCLUSIONS AND IMPLICATIONS

Study findings suggest that opportunities exist for improving diabetes management for LTC residents with T2DM.

Age-dependent prevalence of type 2 diabetes, cardiovascular risk profiles and use of diabetes drugs in Germany using health claims data

AIMS

This study evaluates type 2 diabetes mellitus (T2DM) prevalence in Germany, focusing on patients at risk for, or with already established, cardiovascular disease (CVD), as well as their antidiabetic and cardiovascular treatments.

MATERIALS AND METHODS

Using anonymized claims data from the WIG2 database, we calculated 2018 T2DM prevalence, extrapolating rates to the German statutory health insurance population. In the study period, 3 376 228 patients were eligible in the database. Forming antidiabetic medication groups, we evaluated treatment regimens of patients at risk for, or with already established CVD, based on the REWIND study criteria. We also evaluated their CVD medication prescriptions.

RESULTS

Statutory health insurance extrapolated T2DM prevalence was estimated at 11.9%, with higher prevalence rates in older patients. When only patients with prescriptions of antidiabetic drugs were included, prevalence was 7.6%. At least 94% of patients with T2DM medication had at least one risk factor (without considering age) according to REWIND criteria, while 67%-80% had at least two risk factors depending on treatment received. Patients taking insulin combined with oral therapy comprised the largest proportion of patients with at least two REWIND risk factors. Approximately 85% of all patients with T2DM in the population were treated with antihypertensive medication.

CONCLUSIONS

T2DM is widespread and affects older patients particularly. Most patients with T2DM had at least one CV risk factor, and about half already had established CVD. Early prevention of CVD, which disproportionately affects patients with T2DM, is necessary. Furthermore, the treatment of older patients with T2DM with insulin is still common and needs further evaluation.