PracticeUpdate Diabetes June 2019

EDITOR’S PICKS 10

Deintensification in Older Patients With Type 2 Diabetes Diabetes, Obesity & Metabolism Take-home message • In this meta-analysis of 10 studies, the authors evaluated the effects of deintensi- fication of antihyperglycemic medications in elderly patients. While some studies looked at the effects of reduced dosages or changes in medication, most of the studies evaluated complete discontinuation of antihyperglycemic treatment. HbA1c levels remained largely stable after deintensification, and increases in falls and hospitalizations were not associated with deintensification. Adverse event rates were similar in patients who continued on therapy compared with those who discontinued treatment. • The authors concluded that, although some evidence supports the safety and possible benefit of deintensification of antihyperglycemic medication in elderly patients, specific patient factors should determine the treatment plan for each patient.

Abstract BACKGROUND Guideline bodies recommend less strict glycaemic tar- gets in older people with diabetes. It is uncertain whether the benefits of deintensification or de-prescribing, commonly employed by clinicians to achieve the less strict targets, outweighs the harms in these patients. We conducted a systematic review of published evidence, to assess deintensification approaches and rates and evaluate the harms and ben- efits of deintensification with antidiabetic medication and other therapies amongst older people (≥ 65 years) with type 2 diabetes with or without cardiometabolic conditions. METHODS We identified relevant studies in a literature search of MEDLINE, Embase, Web of Science, and Cochrane databases to 30 October 2018. Data was extracted on baseline characteristics, details on deintensifi- cation, and outcomes and was synthesized using a narrative approach. RESULTS Ten studies (observational cohorts and interventional studies) with data on 26,558 patients with comorbidities were eligible. Deintensifica- tion approaches included complete withdrawal, discontinuation, reducing dosage, conversion, or substitution of at least one medication, but major- ity of studies were based on complete withdrawal or discontinuation of antihyperglycaemic medication. Rates of deintensification approaches ranged from 13.4% to 75%. Majority of studies reported no deterioration in HbA1c levels, hypoglycaemic episodes falls or hospitalisation on dein- tensification. On adverse events and mortality, no significant differences were observed between the comparison groups in the majority of studies. CONCLUSION Available but limited evidence suggests that the benefits of deintensification outweighs the harms in older people with type 2 diabetes with or without comorbidities. Given the heterogeneity of patients with dia- betes, further research is warranted on which deintensification approaches are appropriate and beneficial for each specific patient population. Deintensification in Older Patients With Type 2 Diabetes: A Systematic Review of Approaches, Rates and Outcomes. Diabetes Obes Metab 2019 Apr 01;[EPub Ahead of Print], S Seidu, P Topsever, CE Hambling, et al. www.practiceupdate.com/c/81938 " For now, we do not have good data showing that ‘willful stopping’ of medication does not have any detrimental effects. In fact, we have the opposite with the data from the ADVANCE study. "

COMMENT By Peter Lin MD, CCFP

De-Prescribing in Patients With Diabetes – Is It Safe? F or as long as I can remember, guidelines have focused on intensifying therapy, and that is appropriate because with each study we proved that lowering the A1c protected the microvasculature. For blood pressure and lipids, each study tested lower and lower levels, and so we all started to intensify our therapies in the hopes of providing further protection for our patients. This was evidence-based medicine. Recently, the concept of over-treatment has become a focus. As more and more of our patients become elderly, we wonder if we are over-treating and maybe even causing side effects like hypoglycemia and hypotension, which could lead to falls and fractures. Hence, a movement to de-intensify therapy and to de-prescribe in our elderly patients was underway. Now, every- one would agree that removing sedatives or agents with high anticholinergic effects is a good idea for our elderly patients, but now the conversation is about removing antihypertensive, anti-lipid, and anti-glycemic therapies. We have many randomized controlled trials putting patients on medications and intensifying medications, but there are very few studies for de-prescribing. That is why I was so delighted when I read the title of this paper, “ De-Intensification in Older Patients With Type 2 Diabetes: A Systematic Review of Approaches, Rates and Outcomes. ” The review included 10 studies with data from 26,558 patients. The authors said the “majority of studies were based on com- plete withdrawal or discontinuation of anti-hyperglycemic medication.” They went on to say that the “majority of studies reported no deterioration in HbA1c levels, hypoglycemic epi- sodes falls or hospitalization on de-intensification.” They also said, “on adverse events and mortality, no significant differences were observed between the comparison groups in the majority of studies.” So, based on these statements, one would conclude

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