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Deintensifying type 2 diabetes care – when and how

Kevin Fernando
In some individuals with type 2 diabetes, particularly older people and those with multiple comorbidities, the risks of tight blood glucose control outweigh the benefits. However, primary care clinicians may be less skilled at deintensifying diabetes care than at initiating it. The featured article proposes an approach to the individualisation and deintensification of diabetes care in those who might benefit from it, and how to reach an agreed plan with them.

“In the end, it’s not the years in your life that count, it’s the life in your years.” – Abraham Lincoln, 1809–1865

In a previous piece for Diabetes Distilled, I discussed a recently published expert consensus statement on the management of older adults with type 2 diabetes in which the relative merits of various drug classes in older people with diabetes were summarised, and holistic glycaemic management algorithms were provided according to frailty status.

This equally useful BMJ Practice Pointer discusses when and how to deintensify type 2 diabetes care. Generally, we are proficient in primary care at commencing medications. However, we are not so proficient at discontinuing them.

This article stresses that appropriate deprescribing of diabetes medications and the omission of diabetes-specific assessments that no longer improve the quality of life of older adults should be central and routine for any diabetes review for the older person. Additionally, pivotal to any ongoing management decisions are patient choice and values, which should guide treatment goals and facilitate a shared decision-making process.

It is well established that glycaemic control that is too tight in frail older individuals living with type 2 diabetes, or those with multiple comorbidities, is associated with a higher risk of severe hypoglycaemia, falls, hospitalisation and death. Moreover, we lack evidence that tight glycaemic control in these populations delays long-term complications and improves outcomes.

The authors propose a pragmatic and holistic approach to individualisation and deintensification of diabetes care in the older adult (see Figure).

Older adults living with type 2 diabetes require review of their diabetes and diabetes-specific health complications, such as diabetic foot disease. They also benefit from regular assessment of nutritional status, cognitive function and mood, as well as functional and mobility status.

The authors suggest that diabetes care should be deintensified when there is evidence of:

  • Short life expectancy.
  • Low cognitive function.
  • Low functional status.
  • Patient preference for less intensive care.
  • Severe or high number of comorbidities.
  • Long diabetes duration.
  • Vascular complications.
  • Hypoglycaemia and other adverse drug events.
  • Low level of resources and support.

 

They also provide treatment goals according to patient status (see Table), like the previously discussed expert consensus statement.

The authors also discuss how to specifically deintensify diabetes care. Deintensification not only refers to cessation of antidiabetes drugs, but also to the reduction in self-monitoring of blood glucose, the cessation of other drugs and the reduction in frequency of diabetes-specific assessments (e.g. checking of urinary ACR).

Deprescribing antidiabetes drugs can involve stopping or reducing the dose of a specific drug (e.g. sulfonylureas) or switching to an alternative class with a more favourable risk–benefit ratio, such as a lower risk of hypoglycaemia (e.g. DPP-4 inhibitors).

Deprescribing other medications should be done on an individual basis; blood pressure and lipid-lowering goals can be relaxed in frailty, and medications reduced or stopped accordingly. There is a similar lack of guidance on deprescribing in the context of cardiovascular disease.

Finally, in those at end-of-life care, or with severe frailty or dementia, all specific diabetes assessments that do not improve quality of life can be stopped (e.g. assessment of peripheral arterial disease, chronic kidney disease, BMI or smoking status).

The authors acknowledge that conversations regarding deintensification of care can be challenging. They suggest using neutral language to explain the benefits and harms of each option and to be open about our own concerns (e.g. risk of hypoglycaemia or acute kidney injury). Furthermore, normalising deintensification of care and reinforcing that it is a core part of providing good care can help avoid it being misinterpreted as rationing of treatment based on age or functional status.

Click here to read the article in full.

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