Spotlight on glycemic control and patient age

Two recent studies looked at how glycemic control varies by age, including the paradox of greater hyperglycemia among younger patients.

The first study, published by BMJ Open Diabetes Research and Care on Feb. 19, was a retrospective analysis of claims data for 194,157 patients with type 2 diabetes. Among those 18 to 44 years old, the mean HbA1c level was 7.7%, compared to 6.9% in those ages 75 years and older. Insulin use was less common in the older group (odds ratio [OR], 0.51; 95% CI, 0.48 to 0.54), while sulfonylurea use was more common (OR, 1.36; 95% CI, 1.29 to 1.44). The study also found that patients with comorbidities had higher HbA1c levels, more use of insulin, and less use of sulfonylureas than those without. “Our findings confirmed the presence of a risk/treatment paradox, with overall worse glycemic control and low rates of insulin therapy despite elevated HbA1c levels among younger patients and patients with few comorbidities,” the study authors said. They speculated that younger patients might face higher health care costs, more difficulty accessing care, or conflicting priorities as barriers to control. The results suggest that there are opportunities for treatment deintensification in older patients and improved access to care and glycemic control in younger patients, the authors said. They encouraged clinicians to engage in shared decision making with consideration of patients' comorbidities, age, and goals and preferences.

The second study, published by Diabetes Care on March 4, used data from one health care system on 32,137 adults who were diagnosed with diabetes, defined as a first HbA1c level of 6.5% or higher, at either ages 21 to 44 years (26.4%) or ages 45 to 64 years (73.6%). The younger group had a higher initial mean HbA1c level: 8.9% versus 8.4% (P<0.0001). In the year after diagnosis, the younger group had lower odds of achieving an HbA1c level less than 7% (adjusted OR, 0.70; 95% CI, 0.66 to 0.74), even after accounting for initial HbA1c level. The younger group also had a lower rate of in-person primary care contact during the year (adjusted OR, 0.82; 95% CI, 0.76 to 0.89) but a similar rate of telephone contact. The younger patients were more likely to receive metformin (adjusted OR, 1.20; 95% CI, 1.12 to 1.29) but less likely to adhere to it (adjusted OR, 0.74; 95% CI, 0.69 to 0.80). Some of the causes of these differences are likely not modifiable, but some are, according to the study authors. “Tailored treatment strategies that address the more severe hyperglycemia and obesity seen at diagnosis and the unique treatment barriers present among this higher-risk younger-onset population are needed in order to support timely achievement of recommended treatment goals that are associated with improved long-term outcomes,” they said. Alternative strategies to connect with these patients, such as more use of technological tools, might be helpful, the authors suggested.