Deintensification in older patients with type 2 diabetes: A systematic review of approaches, rates and outcomes

Seidu, Samuel; Kunutsor, Setor K; Topsever, Pınar; Hambling, Clare; Cos, Francesc Xavier; Khunti, Kamlesh

doi:10.1111/dom.13724

Cited by 63 publications

(76 citation statements)

References 53 publications

(143 reference statements)

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“…Figure 12.1 depicts an algorithm that can be used to simplify the insulin regimen (75). There are now multiple studies evaluating deintensification protocols that, in general, demonstrate that deintensification is safe and possibly beneficial for older adults (78). Table 12.2 provides examples of and rationale for situations where deintensification and/or insulin regimen simplification may be appropriate in older adults.…”

Section: Beyond Glycemic Controlmentioning

confidence: 99%

12. Older Adults:Standards of Medical Care in Diabetes—2021

2020

Diabetes Care

167

119

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The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

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Section: Beyond Glycemic Controlmentioning

confidence: 99%

12. Older Adults:Standards of Medical Care in Diabetes—2021

2020

Diabetes Care

167

119

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“…[7][8][9][10] To date, there is limited evidence regarding the benefits and risks of deprescribing in people with diabetes. [11][12][13] Potential overtreatment appears to be common among older people with diabetes, and deprescribing may be difficult to implement in practice. 12,[14][15][16] Clinical guidelines for the treatment of diabetes and cardiovascular risk factors focus more on intensification than on deintensification of medications.…”

mentioning

confidence: 99%

Rates, determinants and success of implementing deprescribing in people with type 2 diabetes: A scoping review

2020

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Background Individualizing goals for people with type 2 diabetes may result in deintensification of medication, but a comprehensive picture of deprescribing practices is lacking. Aims To conduct a scoping review in order to assess the rates, determinants and success of implementing deprescribing of glucose‐, blood pressure‐ or lipid‐lowering medications in people with diabetes. Methods A systematic search on MEDLINE and Embase between January 2007 and January 2019 was carried out for deprescribing studies among people with diabetes. Outcomes were rates of deprescribing related to participant characteristics, the determinants and success of deprescribing, and its implementation. Critical appraisal was conducted using predefined tools. Results Fourteen studies were included; eight reported on rates, nine on determinants and six on success and implementation. Bias was high for studies on success of deprescribing. Deprescribing rates ranged from 14% to 27% in older people with low HbA1c levels, and from 16% to 19% in older people with low systolic blood pressure. Rates were not much affected by age, gender, frailty or life expectancy. Rates were higher when a reminder system was used to identify people with hypoglycaemia, which led to less overtreatment and fewer hypoglycaemic events. Most healthcare professionals accepted the concept of deprescribing but differed on when to conduct it. Deprescribing glucose‐lowering medications could be successfully conducted in 62% to 75% of participants with small rises in HbA1c. Conclusions Deprescribing of glucose‐lowering medications seems feasible and acceptable, but was not widely implemented in the covered period. Support systems may enhance deprescribing. More studies on deprescribing blood pressure‐ and lipid‐lowering medications in people with diabetes are needed.

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“…Some studies suggested the added value of de‐intensification that outweighs the harm, particularly in older patients. However, to date, there is no solid established strategies on how to implement antidiabetic therapy de‐intensification to prevent the harm of overtreatment 23,42 …”

Section: Discussionmentioning

confidence: 99%

The perspectives of physicians regarding antidiabetic therapy de‐intensification and factors affecting their treatment choices—A cross‐sectional study

et al. 2020

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Background: Comprehensive diabetes management includes an appropriate dietary plan, exercise, and antidiabetic medications. Nevertheless, the target glycaemic control is not always achieved using single antidiabetic, patients may need to start treatment intensi cation by increasing the dose of the single antidiabetic agent or by the administration of antidiabetic combination therapy. However, it has been shown that intensive antidiabetic therapy should be used carefully as it is associated with an increased risk of adverse events and death. The aim of this study is to understand physicians' perspectives regarding treatment de-intensi cation and factors affecting their treatment choice for patients with type 2 diabetes mellitus. Methods: A cross-sectional study was conducted in governmental specialised primary and secondary care units in Saudi Arabia using online questionnaire. Two previously validated questionnaires were used to understand physicians' awareness of, agreement with, and their practices of individualising HbA1c goals and antidiabetic treatment de-intensi cation, and to assess factors affecting physicians' treatment choice when prescribing antidiabetic treatment for patients with type 2 diabetes mellitus. Study population were physicians who are treating patients with diabetes mellitus during the period between October 2018 and May 2019. Results: A total of 205 physicians have participated in the study. Approximately 50% of physicians had family medicine speciality (n = 98, 47.8%). The majority of physicians (n = 183, 89.3%) were familiar with the concept of HbA1c goals individualisation. However, only 66.3% of them (n = 136) reported that they apply it either always or most of the time. 58.5% (n = 120) of physicians reported that they would not initiate conversations about de-intensifying antidiabetic therapy even if their patients had a stable HbA1c values for one year. Physicians showed higher consideration to objective patient clinical data and their assessment of patient's health status, with minor consideration to patient-related factors. Conclusions: Healthcare professionals should focus more on implementing contemporary practices and applying any necessary treatment de-intensi cation. Subjective patient factors should be taken into account, as these factors are associated with better disease management.

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Deintensification in older patients with type 2 diabetes: A systematic review of approaches, rates and outcomes

Cited by 63 publications

References 53 publications

12. Older Adults:Standards of Medical Care in Diabetes—2021

12. Older Adults:Standards of Medical Care in Diabetes—2021

Rates, determinants and success of implementing deprescribing in people with type 2 diabetes: A scoping review

The perspectives of physicians regarding antidiabetic therapy de‐intensification and factors affecting their treatment choices—A cross‐sectional study

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