Age-Dependent Hemoglobin A1c Therapeutic Targets Reduce Diabetic Medication Changes in the Elderly

Abstract

Objective: To assess whether implementation of age-dependent therapeutic targets for high hemoglobin A1c (HbA1c) changed clinicians’ ordering of diabetes medications for older adults. Background: In 2016, Kaiser Permanente Southern California (KPSC) changed the therapeutic targets for alerting clinicians about high HbA1c results in the electronic health record, KP HealthConnect (KPHC). Previously, all HbA1c results ≥7.0 percent were flagged as high in adult patients with diabetes. Starting in 2016, HbA1c therapeutic targets were relaxed to <7.5 percent for patients age 65 to 75, and to <8.0 percent for patients over age 75 to reduce treatment intensity and adverse events. Methods: This retrospective analysis used logistic regression models to calculate the change in odds of a medication change following an HbA1c result after age-dependent HbA1c flags were introduced. Results: The odds of medication change decreased among patients whose HbA1c targets were relaxed: Odds Ratio (OR) 0.72 (95 percent CI 0.67–0.76) for patients age 65–75 and HbA1c 7.0 percent–7.5 percent; OR 0.72 (95 percent CI 0.65–0.80) for patients over age 75 and HbA1c 7.0 percent–7.5 percent; and OR 0.67 (95 percent CI 0.61–0.75) for patients over age 75 and HbA1c 7.5 percent–8.0 percent. In the age and HbA1c ranges for which the alerts did not change, the odds of medication change generally increased or stayed the same. There was little evidence of medication de-intensification in any group. Conclusions: These findings suggest that the change in therapeutic targets was associated with a reduction in medication intensification among older adults with diabetes.

Effects of colchicine use on ischemic and hemorrhagic stroke risk in diabetic patients with and without gout

“…For example, in elderly DM who have multiple chronic diseases (aDSCI ≥ 1), mild to moderate dementia, and shortened life expectancy, HbA1c should target 7.1–8%, fasting and pre-meal plasma glucose at 90–150 mg/dl, and overnight plasma glucose at 100–180 mg/dl. Thus, if those elderly patients with DM could achieve the target level such as (HBA1c, 6.5–7.5% in healthy older adults, 7.1–7.8% in heart failure, 7.5–8.5% in frail) after lifestyle therapies, the antidiabetic medications may be not necessary in select case such as residential aged care facilities 51 – 54 . Meanwhile, the frail elderly may be censored or dead before starting use of antidiabetic medications.…”

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“…In sensitivity analyses, we also considered alternative definitions of glycemic control (HbA 1c level <8% [64 mmol/mol]) and severe hyperglycemia (HbA 1c level >9% [75 mmol/mol]) . Sensitivity analyses were also conducted using age-adjusted estimates and 2 age-specific cutoff models: (1) HbA 1c level less than 7% for nonpregnant adults and HbA 1c level less than 8% for patients older than 75 years and (2) HbA 1c level less than 7% for nonpregnant adults younger than 65 years, HbA 1c level less than 7.5% (58 mmol/mol) for adults aged 65 to 74 years, and HbA 1c level less than 8% for adults aged 75 years or older …”

“…9 Sensitivity analyses were also conducted using age-adjusted estimates and 2 age-specific cutoff models: (1) HbA 1c level less than 7% for nonpregnant adults and HbA 1c level less than 8% for patients older than 75 years and (2) HbA 1c level JAMA Network Open | Diabetes and Endocrinology less than 7% for nonpregnant adults younger than 65 years, HbA 1c level less than 7.5% (58 mmol/mol) for adults aged 65 to 74 years, and HbA 1c level less than 8% for adults aged 75 years or older. 10,11…”