Avoiding hypoglycemia most compelling reason for deintensifying diabetes meds

Researchers presented older adults with type 2 diabetes with three scenarios in which deintensification may be indicated—poor health, limited life expectancy, and high hypoglycemia risk—and found that 8%, 4%, and 75%, respectively, viewed deintensification positively.

The idea that life expectancy affects glycemic targets is initially confusing to patients, but education on this topic may help older adults with diabetes make informed choices about deintensification, a study found.

To explore the perspectives of older adults about deintensifying diabetes medications, researchers conducted individual semistructured interviews of 24 community-dwelling adults ages 65 years and older with type 2 diabetes who were taking one or more diabetes medications and had a most recent HbA1c value less than 7.5% within the past 12 months. As part of the interview, participants were presented with three clinical scenarios where medication deintensification may be indicated: poor health, limited life expectancy, or high risk for hypoglycemia.

Participants completed one semistructured interview by phone or video between January and June 2021, along with brief questionnaires about their health history. Electronic health records provided current diabetes medications, comorbidities, and most recent HbA1c value. Interviews were independently coded by two investigators. Researchers parsed out major themes and subthemes of the interviews and coded responses to the clinical scenarios as positive (in favor of deintensification), negative, or ambiguous. Results were published Sept. 29 by the Journal of General Internal Medicine.

The first of four major themes was patients' fears of losing control of their diabetes, which participants weighed against the benefits of taking less medication, the second theme. The study authors noted that few participants viewed glycemic control below target as a reason for deintensification and a majority would restart the medication if their home glucose measurements increased. The third theme was that some participants were anchored to their current diabetes treatment driven by unrealistic views of medication benefits. The fourth theme was that a trusting patient-clinician relationship was a positive influence. In clinical scenarios of poor health, limited life expectancy, and high hypoglycemia risk, 8%, 4%, and 75% of participants, respectively, viewed deintensification positively.

The study authors noted that deintensification is an opportunity for shared decision-making but that clinicians must understand patients' beliefs about their medications and address misconceptions. Discussion of how deintensification can prevent hypoglycemia may be a helpful frame for discussion, they added. They also noted that the idea of deintensifying diabetes medications due to limited life expectancy or poor health status predominantly confused patients or elicited strong negative reactions, and the idea of giving less aggressive diabetes treatment to patients with poor health was counterintuitive to patients. However, study participants supported deintensification during end-of-life care and were receptive to explanation of how life expectancy affects the balance of a medication's benefits and harms.

“These findings suggest that patients could appreciate these concepts with more input from their provider than was given in our brief study questions. Therefore, educating older adults about how life expectancy affects glycemic targets may help them make informed choices about deintensification, further emphasizing the need to develop communication approaches in this area,” the authors wrote.