PracticeUpdate Diabetes June 2019

EDITOR’S PICKS 11

that removing of medications is safe in the elderly and that it would save money and take care of this over-treatment issue. However, to my surprise, the number of patients in each study was shockingly low. For 7 of the 10 studies, the numbers of patients in the study were 98, 141, 8, 35, 20, 106, and 5. Also, the study duration was very short. For these 7 studies, the durations were 6 months, 1 year, 1 year, 3 months, 24 weeks, N/A, and 3 months. So, clearly, not large enough numbers and not long enough dura- tion to be able to conclude that there was no ill effect associated with discontinuing medications. Also, not all of the studies had A1c readings because many were retrospective database studies. Now, to be fair, there were three studies that had large numbers. Let’s take a closer look at those studies. The NHCP (Medicare beneficiaries) study had 8751, and the study period was 1 year. The authors looked at patients who stopped anti-glycemic agents. There were no causes listed as to why patients stopped, but 13.4% of the patients who were discharged from the hospital were off their medications. The outcome of the study was the readmission rate, and there was no difference. There were no data on why they stopped their medication and no A1c data, only readmission data. The Veteran Affairs database study had 6254 patients, but the study period was only 5 months. That study targeted patients at risk of hypoglycemia or who had an eGFR <50 mL/min per 1.73 m 2 , and these patients were told to stop taking glyburide and to use other agents instead. So, 71% stopped glyburide; but, in the non-targeted group, 56% also stopped glyburide. So, both groups had people stopping glyburide and both groups could go onto other anti-glycemic agents. The study conclusion was that there was no difference in A1c or hypoglycemia rates. This study is large, but it was not designed to answer our question, which is “is it safe to stop medications?”

The ADVANCE study was also included in this analysis. It had 11,140 patients with over 4.3 years of follow-up, and it was a well-done randomized controlled trial. However, it only looked at patients who stopped their blood pressure medications, not their glucose agents. There were 14% of patients who stopped their antihy- pertensive due to side effects. The study found that that group of patients had a huge increase in event rates. The hazard ratio for macrovascular events was 3.23 (2.75–3.79); for microvascular events, 1.38 (1.11–1.71); and for mortality, 7.99 (6.92–9.21). This goes against the authors’ conclusion that there was no harm in stop- ping therapy in the elderly. Sadly, this paper does not answer whether we can de-prescribe safely in elderly patients with diabetes. The data available are of poor quality. In well-conducted trials like the ADVANCE study, it is clear that patients who can’t take their blood pressure medi- cations are at an extremely high risk for developing micro- and macrovascular disease and moving on to death. 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 oppo- site with the data from the ADVANCE study. No matter how we think stopping medications may be good for our patients, we still need to do proper studies to prove it. Oth- erwise, we are just practicing opinion-based medicine instead of evidence-based medicine. Our patients deserve evidence-based medicine.

Dr. Lin is Director of Primary Care Initiatives at the Canadian Heart Research Centre and Medical Director of LinCorp Medical Inc.

VOL. 3 • NO. 2 • 2019