Overtreatment linked to poor outcomes for older adults with diabetes


medwireNews: Researchers note that older adults with diabetes are often treated with an intense glycemic goal, putting them at risk for poor outcomes, especially when high-risk drugs are used.

Iliana Lega (Women’s College Hospital, Toronto, Ontario, Canada) and colleagues describe their results in their population-based cohort as “worrying because the median age was 80 and individuals had high levels of exposure to comorbidities”.

However, they also emphasize the importance of considering frailty, which they believe predicts poor outcomes better than age or comorbidities.

“Therefore, intense glycemic goals and high-risk drugs should be avoided, especially in frail, older adults.”

The researchers examined 108,620 people aged 75 or over who had received a prescription for one or more glucose-lowering drugs from September 2014 to August 2015. All study participants had a glycated hemoglobin (HbA1c) level of 69 mmol / mol (8.5%) or less, since people with higher values ​​were considered to have additional risk factors for poor results.

Of these people, 61.1% received treatment with an intense glycemic goal because their HbA1c levels were below 53 mmol / mol (7.0%), while 38.9% had a higher level and therefore had a conservative treatment goal.

Around a third of those treated with an intensive target (21.6% of the total cohort) received drugs at high risk of hypoglycemia, namely sulfonylureas or insulin.

The researchers note that despite the guidelines at the time, this recommends less strict blood sugar control for the elderly, especially those with comorbidities.

“Strategies to improve the dissemination and implementation of practice guidelines, such as communication campaigns, clinician and patient education, decision support tools, audits and feedback, are critical to aligning diabetes practice with recommendations for this vulnerable population,” they write in Diabetologia.

During the 30 days following the index HbA1c measurement, 0.92% of subjects who received intensive control with high-risk drugs required urgent or hospital treatment for a diabetes problem, including hypoglycemia, or died for some reason.

This compared with rates of 0.67% for those who received conservative control with high-risk drugs, 0.42% and 0.41% for those who were treated with low-risk drugs to achieve intense and conservative goals, respectively.

In an analysis correcting the propensity for overtreatment, the risk of poor outcomes in people intensively treated with high-risk drugs increased by 49% compared to conservative treatment with low-risk drugs.

Intensive treatment itself was associated with an increased risk, which was reflected in a significant increase of 25% for intensive versus conservative treatment with high-risk drugs. However, there was a greater risk increase of 48% for intensive control with high risk agents compared to low risk agents.

This suggests that “the dangers of intense control may be primarily caused by the use of high-risk drugs for hypoglycemia,” say the researchers.

Indeed, the risk of the secondary outcome of emergency or hospital treatment for hypoglycemia was almost seven-fold higher with intensive treatment with high-risk drugs than with conservative treatment with low-risk drugs.

“While the use of insulin in older adults may be appropriate in certain situations (e.g., decreased kidney function, loss of insulin secretory capacity), clinicians need to use it with caution and aim for higher glycemic goals in those situations,” the team notes.

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Diabetology 2021; doi: 10.1007 / s00125-020-05370-7