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Can Aggressive Glycemic Control in Adults With Diabetes Be Harmful?

Dec 23, 2017
 

The first study to examine overtreatment and deintensification in a Medicare population with diabetes.

Treating diabetes requires balancing the short-term and long-term harm between under treatment and potential over treatment. In some older people, deintensification of diabetes therapy is often clinically appropriate and is a safer route, because the benefit of aggressive diabetes treatment declines with age while the risks of falls and other issues that come with low blood sugar increase. A new research in the Journal of General Internal Medicine suggests that Medicare recipients are more frequently over treated than under treated for diabetes and rarely have their regimens deintensified, leaving them at increased risk of potentially life-threatening complications. “Severe hypoglycemia, cardiovascular events, cognitive impairment, fractures, and death associated with overtreatment of diabetes can happen at any time,” says Dr. Maciejewski and colleagues.

Researchers analyzed Medicare claims data and prescription refills from 78,792 Medicare recipients in 10 states who were over age 65 and had diabetes to identify patients who were potentially overtreated, (HbA1c < 6.5% with fills for any diabetes medications beyond metformin) and those who were undertreated (HbA1c > 9%). The results were compiled by a team of researchers from Duke University, the University of Michigan and the VA hospitals in Durham, North Carolina and Ann Arbor, Michigan. Of 78,792 Medicare recipients with diabetes, 8,560 (10.9%) had very low blood sugar levels that suggested they were potentially over treated. Overtreatment of diabetes was more common among patients over 75 years of age and those who have low incomes or serious disability (13.4%) that qualified for both Medicare and Medicaid (p < 0.001). Those who lived in urban areas or were of Hispanic origin were less likely to be overtreated (p = 0.009). Therapy was deintensified for 14% of overtreated patients with diabetes. Patients who had six or more chronic conditions, or who lived in urban areas or had frequent outpatient visits, were more likely to get a deintensification of diabetes therapy.

Several major studies as well as new clinical guidelines for diabetes management have recommended to relax glycemic-control in older adults with multiple chronic conditions, limited life expectancy, diabetic complications, or functional impairment. The American Geriatrics Society (AGS) recommends that the only medication older adults with diabetes should be on if they have an HbA1c level below 7.5% is metformin. While 10.9% of all the Medicare participants in the study were overtreated to a very low A1c level, only 6.9% of the participants were undertreated and had A1c levels over 9%. “The oldest Medicare beneficiaries are the least likely to benefit from tight glycemic control and most likely to be harmed, so it is troubling that they were more likely to be overtreated and less likely to have their medication regimens de-intensified,” explains Jeremy Sussman, who is a member of the VA Center for Clinical Management Research and the U-M Institute for Healthcare Policy and Innovation. “By focusing on both overtreatment and undertreatment ends of the diabetes quality spectrum, we can best begin to improve the quality of diabetes care in all respects, ensuring that patients get needed care while avoiding unnecessary potential harm,” he adds.

An effective treatment of diabetes requires individualized treatment for the patients. This study helps to identify those who may benefit from a more intensive treatment as well as those who may need less medication. “By focusing at both the overtreatment and undertreatment ends of the diabetes quality spectrum, we can best begin to truly improve the quality of diabetes care, ensuring that patients get needed care while avoiding unnecessary potential harm.” Sussman and his colleagues say.

Practice Pearls:

  • Effective treatment of diabetes requires a major shift in approach toward individualized treatment based on potential for individual risk and benefit.
  • Older adults are least likely to benefit from tight glycemic control and most likely to be harmed.
  • The updated guideline from American Geriatrics Society (AGS) suggests that in order to improve the care of older adults with diabetes, medications other than metformin should be avoided in the older patient with an HbA1c of <7.5%.

Reference:

Matthew L. Maciejewski, Xiaojuan Mi, Jeremy Sussman, Melissa Greiner, Lesley H. Curtis, Judy Ng, Samuel C. Haffer, Eve A. Ker. Overtreatment and Deintensification of Diabetic Therapy among Medicare Beneficiaries. Journal of General Internal Medicine. 2017 Sep 13.

Kay Lynn Tran, Doctor of Pharmacy Candidate: Class of 2018; LECOM College of Pharmacy