Deintensifying treatment benefits older patients with type 2 diabetes

The reasons that deintensification (defined as the de-escalation or down-titration of glucose-lowering therapy by reducing the dose, deprescribing or substituting one agent for a less potent glucose-lowering therapy) should be seen as an alternative to existing treatment approaches in older people with type 2 diabetes (Hambling et al, 2019; Sinclair et al, 2019) have been detailed in a timely and interesting article by Seidu et al (2019), summarised in our Digest here. The basis for considering deintensification approaches, according to the authors, include: 

• The common dilemma of clinical inertia versus overtreatment
• Concerns about poor glucose control (which increases vascular risk) versus the consequences of hypoglycaemia 
• The additional risks of falls and hospital admissions if treatment is more aggressive. 

The authors point out that the hazards of overtreatment are often accentuated by the presence of frailty and multiple comorbidities leading to inappropriate or unsafe drug treatments. As there is currently no robust guidance on which approaches are most effective due to a lack of evidence relating to intervention studies (clinical trials) in older people with diabetes, the authors attempt to clarify the value of deintensification as an intervention to bring clinical benefits by using systematic review methods. 

The authors identified 10 observational and intervention studies including more than 26,000 subjects aged greater than 65 years that used a variety of deintensification approaches, such as complete withdrawal of therapy, discontinuation, reducing the dosage, or conversion or substitution of at least one medication. Rates of deintensification were as high as 75% in some studies; in general there were no significant changes in or adverse effects on HbA_1c, falls, hypoglycaemia or hospitalisation when compared with control groups. The authors were fair in stating that deintensification was associated with some defined benefits but accepted that the lack of homogeneous study designs and outcomes combined with studies of relatively short duration limit the full interpretation and clinical implications of the work. 

The findings are similar to those reported previously in a review that likewise used a systematic review methodological approach to examine the benefits and consequences of deintensification in older people with type 2 diabetes (Abdelhafiz and Sinclair, 2018). This review also demonstrated that deintensification did not lead to a deterioration in glycaemic control and was able to characterise those most likely to be overtreated as frail with weight loss, renally impaired, demented, those with a high comorbidity profile and those of very advanced age.

Deintensification is still a relatively untested and unproven method of attenuating the concerns that clinicians have about overtreatment and polypharmacy issues in older people with diabetes. Its potential clinical value combined with reduced therapy costs make deintensification an attractive area for commissioners of diabetes healthcare services. However, greater consistency and relevance in which outcomes are used in future studies will be important: a greater focus on health economics, changes in functional status, and quality of life is essential.

Click the links below to access the latest Diabetes Digests related to older people:

• Reducing diabetes medication benefits older people
• Polypharmacy increases complications and mortality in older people
• Peripheral neuropathy reduces muscle strength in men with diabetes
• Hypoglycaemia increases risk of adverse events in older patients with dementia

Abdelhafiz AH, Sinclair AJ (2018) Deintensificationof hypoglycaemic medications – use of a systematic review approach to highlight safety concerns in older people with type 2 diabetes. J Diabetes Complications 32: 444–50
Hambling CE, Khunti K, Cos X et al (2019) Factors influencing safe glucose-lowering in older adults with type 2 diabetes: A PeRsOn-centred ApproaCh To IndiVidualisEd (PROACTIVE) Glycemic Goals for older people: A position statement of Primary Care Diabetes Europe. Prim Care Diabetes 13: 330–52
Seidu S,Kunutsor SK,Topsever P et al (2019) Deintensification in older patients with type 2 diabetes: A systematic review of approaches, rates and outcomes. Diabetes Obes Metab 21: 1668–79
Sinclair AJ, Abdelhafiz AH, Forbes A, Munshi M (2019) Evidence-based diabetes care for older people with type 2 diabetes: A critical review. Diabet Med 36: 399–413