Intensive glucose-lowering in type 2 diabetes was linked to hypoglycemia in high-complexity patients

More than 20% of patients with type 2 diabetes received treatment more intensive than that recommended by HbA1c-based guidelines, a study of Medicare patients found. Such intensive treatment was associated with significantly higher risk of hypoglycemia, especially among those who were considered clinically complex (patients ages 75 years or older, with dementia or end-stage renal disease, or with 3 or more serious chronic conditions).

The study was published in the July JAMA Internal Medicine and summarized in the June ACP Diabetes Monthly. The following commentary by Daniel I. Steinberg, MD, FACP, was published in the ACP Journal Club section of the Sept. 20 Annals of Internal Medicine.

The study by McCoy and colleagues further substantiates that certain patients with diabetes are overtreated and that such overtreatment is harmful. 19% of high-complexity patients (88% ≥75 years of age) received intensive treatment, which tripled the risk for hypoglycemia. Potential factors contributing to this increased risk in complex patients include less use of metformin and more use of sulfonylureas at index test, dementia or milder cognitive deficits hampering safe medication compliance, and use of more nondiabetes medications that can contribute to hypoglycemia.

There is no evidence that tight glucose control in older adults is beneficial. In the study by McCoy and colleagues, all patients had HbA1c levels <7%. For patients ≥75 years of age, this is at odds with the American Geriatrics Society's Choosing Wisely recommendation that medications to achieve HbA1c levels <7.5% should be avoided in most adults ≥65 years of age.

A study of U.S. Veterans Health Administration patients found that deintensification of treatment occurred for only 27% of elderly patients with HbA1c levels <6%. Clinicians should systematically review their practices to identify candidates for deintensification. High-quality evidence to support a specific approach is lacking. Until it is available, the American Geriatrics Society recommendation and the framework offered by the American Diabetes Association, which emphasizes choosing an HbA1c goal based on a patient's health, functional status, life expectancy, resources, and values, are helpful tools.