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As patients move to geriatric care, considerations regarding treatment-related side effects, polypharmacy, comorbidities, and life expectancy become paramount.
This is especially true for older people with type 2 diabetes (T2D) taking insulin and/or sulfonyluria. It is a constant elderly drug that provides excellent glucose control, but poses a significant risk of pathogenic hypoglycemia.
“There's a gap in how we think about diabetes care, as the paradigm is about tight glycemic control and blood pressure and cholesterol control. But as patients age in the 70s, 80s and 90s, they start to fall apart and their treatment goals start to change.” “We need to switch between the strict control paradigms for everyone who depends on the patient to control,” he said.
According to him, the key was improving medication for diabetes (i.e., reducing doses and frequency, or discontinuing potentially harmful drugs).
Grant is the lead author of a randomised study assessing two strategies to improve diabetes medication in 450 primary care patients (mean age, 79 years, SD, 4.0 years), with an average hemoglobin A1C of 7.5% (SD 1.1%). One group of primary care practitioners received academic details including evidence and case-based educational sessions, and study participants assigned to them received healthy lifestyle handouts of attention control (e.g., screening reminders, diets).
The second strategy required academic details and patient advance visitation activation. This included educational handouts to prepare patients assigned to these physicians for future clinical visits. In this study, the content was based on a one-page drug review and helped me discuss my medication goals with healthcare providers.
“The direct intention of the intervention was to promote dropout. We demonstrated that a six-month follow-up involving patients in these discussions would provide nearly twice as much suppression (15.8%) as academic details (9%),” Grant said.
Severe hypoglycemia in elderly patients
Iyagenic hypoglycemia is not only considered a major preventable, treatment-related complication, but is also associated with significant healthy health complications.
“It can cause confusion. People can get involved in accidents and hurt others and themselves,” said Dr. Pankazi Shah, an endocrinologist at the Mayo Clinic in Rochester, Minnesota. “Hypoglycemia can cause arrhythmia in the heart and sudden cardiac death,” he said.
“The risk of dying after the first episode of hypoglycemia is very high,” Shah said. “I'm saying it's going to happen again or something else will happen.”
Patients with T2D landing in hospitals with severe hypoglycemia also have an increased risk of in-hospital mortality, repeated hospitalizations, and poor metabolic control.
In this study, the addition of pre-vision patient intervention had little effect on self-reported hypoglycemia rates, which were similar between the two arms at 6 months. However, this strategy was associated with fewer (but not statistically significant) hospitalizations associated with pathogenic hypotension at 6 months.
Determine the “Who” for Deprescribing
According to Grant, there is no cut-and-paste path or algorithm for the optimal suppression strategy.
However, the findings of the study “showed that involving patients in the discussion led to academic details alone almost twice as much restraint,” he said.
“Determining an individual A1C target for older adults is not easy,” said Dr. Nestoras Mathioudakis, aide to the endocrinology department at Johns Hopkins Medicine at Baltimore and co-medical director of diabetes prevention and education.
Mathioudakis explained that the American Diabetes Association guidelines recommend A1C targets with A1C targets with less than 8% A1C targets for older adults with complex health problems, and do not provide guidance on A1C targets for older adults with extremely complex health problems and limited life expectancy.
Part of the challenge is that people over the age of 75 have a varying overall functional and health status. For an active, healthy 76-year-old with very few comorbidities and long-term expectations, the benefits of continuous glycemic control can outweigh the risk of hypoglycemia, he said.
The question was, “Who am I going to remove? How do I choose that person? I don't think there's any harsh evidence and tools to guide us to make that decision,” Mathioudakis said.
“Let's do this,” Shah added. “We definitely should be suppressed in patients who have been complications from drugs, and because their blood glucose levels are very well controlled, they are likely to develop hypoglycemia or drug complications, with a lifespan of less than 15-20 years,” he added.
Clinical considerations
While pre-visit patients' activation strategies may help promote drug therapy debate and encourage practitioners to consider inhibition, the biggest challenge often lies with the patients themselves. In a related editorial, Scott J. Pira, MD, MHS, assistant professor, lead author of Johns Hopkins Medicine, expressed his hesitation that older people with diabetes might feel towards being taken away.
“There are patients who have been conditioned for decades to get A1C to below 7%, so there is resistance to changes related to the fact that their practice patterns have changed. Conversations with patients are not easy,” says Mathioudakis.
“If we come [these discussions] From two angles, new drugs, SGLT-2 inhibitors, GLP-1 receptor agonists, and dual GLP/GLP-1 receptor agonists are the most effective from a cardiovascular perspective and less dangerous from a hypoglycemia perspective.
“However, there is also debate as to whether it is appropriate for older patients with the initial body mass index. Therefore, hypoglycemia should be assessed. Perhaps automate data from continuous glucose monitors and use alerts in electronic medical records to encourage discussion.
These discussions are addressed, especially in a rigorous primary care setting, and the elephant in the room.
“We need to reassess whether patients need to continue with these medications, reduce numbers and simplify regimens.
“It should be thought of almost every year, if not more frequently, especially when there are side effects,” he said.
This study was funded by the Patient-Centered Results Institute. Grant, Shah and Matthiudakis reported no related financial ties.
Liz Scherer is an independent health/medical journalist. She frequently covers Medscape Medical News and Medscape Global news and features.
