Intensive glycemic treatment may be common, doubles risk of hypoglycemia
Intensive treatment was defined as use of more glucose-lowering medications than recommended by practice guidelines and was found in 18.7% of clinically complex Medicare patients.
More than 20% of patients with type 2 diabetes received intensive treatment that may be unnecessary according to guidelines, and among patients with high clinical complexity, intensive treatment was associated with nearly double the risk of severe hypoglycemia, a study found.
Researchers examined the use of intensive treatment and its association with clinical complexity and incidence of severe hypoglycemia among nonpregnant adults with type 2 diabetes who were not using insulin. Intensive treatment was defined as use of more glucose-lowering medications than recommended by practice guidelines at specific index HbA1c levels. Severe hypoglycemia was determined by medical claims for hypoglycemia during the 2 years after the index HbA1c test. Results appeared online June 6 at JAMA Internal Medicine.
Of 31,542 studied Medicare patients, 3,910 (12.4%) were categorized as having high clinical complexity because they were 75 years or older, had dementia or end-stage renal disease, or had 3 or more serious chronic conditions. Intensive treatment was found in 18.7% of patients with high clinical complexity and 26.5% of those with low clinical complexity. The risk-adjusted probability of intensive treatment was 25.7% (95% CI, 25.1% to 26.2%) in patients with low clinical complexity and 20.8% (95% CI, 19.4% to 22.2%) in patients with high clinical complexity.
In patients with low clinical complexity, the risk-adjusted probability of severe hypoglycemia during the 2 years of follow-up was 1.02% (95% CI, 0.87% to 1.17%) with standard treatment and 1.30% (95% CI, 0.98% to 1.62%) with intensive treatment (absolute difference, 0.28%; 95% CI, −0.10% to 0.66%). In patients with high clinical complexity, the risk-adjusted probability of severe hypoglycemia increased from 1.74% (95% CI, 1.28% to 2.20%) with standard treatment to 3.04% (95% CI, 1.91% to 4.18%) with intensive treatment (absolute difference, 1.30%; 95% CI, 0.10% to 2.50%).
“Treatment deintensification is also an important aspect of individualized diabetes management, and clinical inertia encompasses not only failure to intensify therapy in response to elevated HbA1c levels but also failure to deescalate therapy in response to low HbA1c levels, particularly if treated with multiple glucose-lowering medications,” the authors wrote. “Such failure to deescalate therapy in patients with very low HbA1c levels increases the risk of hypoglycemia, has no proven clinical benefit, exposes patients to potential adverse effects, and increases burden of treatment.”