Scaling Back Diabetes Treatment in Older Patients May Reduce Risks

Aggressive treatment of diabetes mellitus in older patients can cause dangerously low blood sugar levels, disorientation, and falls. Despite these risks, overtreatment is common, and clinicians do not always adjust treatments, a team of researchers has found.

For patients age 70 and older, hypoglycemic conditions may trigger a loss of balance and other risks, suggesting that a de-intensification process during which medications are completely stopped may be an appropriate change for older patients at risk of experiencing extremely low blood sugar levels.

Published online in September 2017 in the Journal of General Internal Medicine, the study reviewed 78,792 Medicare records from 10 states of patients older than age 65 with diabetes mellitus. Duke researcher Matthew Maciejewski, PhD, and University of Michigan internist Jeremy Sussman, MD, MS, were the senior authors leading a team of researchers from Duke University and the University of Michigan as well as Veterans Administration Hospitals in Durham, NC, and Ann Arbor, MI.

The study found that approximately 11% of Medicare patients with diabetes mellitus had laboratory values that suggested overtreatment of their conditions. Only 14% of those patients had a reduction in blood sugar medication refills in the next 6 months.

“For many years, the focus of diabetes treatment has been to treat as intensively as possible,” Sussman says. “But this research should offer new approaches for older patients.”

Determining the clinical implications has not been easy, Maciejewski notes, because undertreatment remains a concern—but not necessarily an overriding one for every patient.

“The benefits of undertreatment must accrue over decades, so to treat diabetes appropriately, we need to find sweet spots where we are limiting the risk of short-term harm but maximizing long-term benefits,” Maciejewski says.

The study recommended that patients with hemoglobin A1C (HbA1C) levels below 6.5% should reduce insulin dosing to lower the risk of hypoglycemia.

Duke endocrinologist Matthew Crowley, MD, says the study suggests that overtreatment is relatively common and that providers may not be responding appropriately when diabetes control is too intensive.

“Recent randomized trials indicate that the risks of tight diabetes control outweigh the benefits for many elderly patients,” Crowley says. “In fact, the American Diabetes Association recommends loosening HbA1C targets for patients at high risk of low blood sugar or who have limited life expectancy or comorbidities such as heart disease.”

Key results from the study include the following:

• Of 78,792 Medicare recipients with diabetes mellitus, 8,560 (10.9%) were potentially overtreated
• Overtreatment was more common among those who were 75 years of age or older and enrolled in Medicaid
• Overtreatment was less common among Hispanics
• Treatment was de-intensified for 15% of the overtreated patients
• Appropriate de-intensification was more common for patients with 6 or more chronic conditions, with more outpatient visits, or who were living in urban areas
• De-intensification was less common for patients older than age 75
• Only 6.9% of Medicare patients were potentially undertreated