Factors influencing safe glucose-lowering in older adults with type 2 diabetes: A PeRsOn-centred ApproaCh To IndiVidualisEd (PROACTIVE) Glycemic Goals for older people

Hambling, Clare; Khunti, Kamlesh; Cos, Xavier; Wens, Johan; Martínez, L.; Topsever, Pınar; Prato, Stefano Del; Sinclair, Alan J.; Schernthaner, Guntram; Rutten, Guy E.H.M.; Seidu, Samuel

doi:10.1016/j.pcd.2018.12.005

Cited by 34 publications

(20 citation statements)

References 113 publications

(91 reference statements)

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“…While valuable evidence-based guidance has been published on the overall management of people aged C 65 years with diabetes [2,3], and international guidance is available that addresses the overall management of frailty in older adults [4], there is limited formal and practical guidance, for primary care teams in particular, on how to vary type 2 diabetes therapy in older people according to their level of frailty. However, the importance of this is beginning to be addressed in recent publications [5,6]. Historically, there has been a lack of routine assessment of frailty, functional status and comorbidities in clinical trials on diabetes, which has contributed largely to the insufficient characterization of older study participants [7].…”

Section: Introductionmentioning

confidence: 99%

Diabetes and Frailty: An Expert Consensus Statement on the Management of Older Adults with Type 2 Diabetes

et al. 2021

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Prognosis and appropriate treatment goals for older adults with diabetes vary greatly according to frailty. It is now recognised that changes may be needed to diabetes management in some older people. Whilst there is clear guidance on the evaluation of frailty and subsequent target setting for people living with frailty, there remains a lack of formal guidance for healthcare professionals in how to achieve these targets.

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Section: Introductionmentioning

confidence: 99%

Diabetes and Frailty: An Expert Consensus Statement on the Management of Older Adults with Type 2 Diabetes

et al. 2021

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“…deintensification) in the older patients with type 2 diabetes and comorbidities remain uncertain. Deintensification, as defined by a position statement from Primary Care Diabetes Europe, is the de‐escalation or down‐titration of glucose‐lowering therapy by reducing the dose, deprescribing, or substituting one agent for a less potent glucose‐lowering therapy . Deintensification also includes deprescribing, which is the process of withdrawal or stopping inappropriate medication, and the ultimate goal is improving outcomes and managing polypharmacy .…”

Section: Introductionmentioning

confidence: 99%

“…Deintensification, as defined by a position statement from Primary Care Diabetes Europe, is the de-escalation or down-titration of glucose-lowering therapy by reducing the dose, deprescribing, or substituting one agent for a less potent glucose-lowering therapy. 23 Deintensification also includes deprescribing, which is the process of withdrawal or stopping inappropriate medication, and the ultimate goal is improving outcomes and managing polypharmacy. 24,25 Deintensification approaches are on the increase and it is becoming an established part of the prescribing process, especially in the management of older patients with multiple comorbidities.…”

Section: Introductionmentioning

confidence: 99%

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

Seidu

Kunutsor

Topsever

et al. 2019

Diabetes Obesity Metabolism

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Aim To assess deintensification approaches and rates and evaluate the harm and benefits of deintensification with antidiabetic medication and other therapies among older people (≥ 65 years) with type 2 diabetes with or without cardiometabolic conditions. Methods We identified relevant studies in a literature search of MEDLINE, Embase, Web of Science and Cochrane databases to 30 October 2018. Data were extracted on baseline characteristics, details on deintensification and outcomes, and was synthesized using a narrative approach. Results Ten studies (observational cohorts and interventional studies) with data on 26 558 patients with comorbidities were eligible. Deintensification approaches included complete withdrawal, discontinuation, reducing dosage, conversion, or substitution of at least one medication, but the majority of studies were based on complete withdrawal or discontinuation of antihyperglycaemic medication. Rates of deintensification approaches ranged from 13.4%–75%. The majority of studies reported no deterioration in HbA1c levels, hypoglycaemic episodes, falls or hospitalizations on deintensification. On adverse events and mortality, no significant differences were observed among the comparison groups in the majority of studies. Conclusion Available but limited evidence suggests that the benefits of deintensification outweigh the harm in older people with type 2 diabetes with or without comorbidities. Given the heterogeneity of patients with diabetes, further research is warranted on which deintensification approaches are appropriate and beneficial for each specific patient population.

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“…Medications for primary prevention were evaluated for potential discontinuation and those for secondary prevention were individualized in accordance with patient goals [18]. (ii) Type 2 Diabetes Mellitus (T2DM): to optimize hypoglycaemic therapy two important proposals were considered: Therapeutic intensity criteria (taking American Diabetes Association (ADA) guidelines as our basis) [20][21][22], we established a maximum HbA1c target for each patient profile, determined by the therapeutic goal agreed on by applying the PCP model. In accordance with the HbA1c target, therapeutic modifications were proposed: an increase or decrease in dose or the start or withdrawal of treatment, according to each case (Table 1).…”

Section: Introductionmentioning

confidence: 99%

Therapeutic optimization through goal-oriented prescription in nursing homes

et al. 2020

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Background People living in nursing homes are highly vulnerable and frail. Polypharmacy and inappropriate prescription (IP) are also common problems. Objectives The objectives of the study are (i) to study the baseline situation and calculate the frailty index (FI) of the residents, (ii) to assess the results of routine clinical practice to do a pharmacotherapy review (patient-centred prescription (PCP) model) (Molist Brunet et al., Eur Geriatr Med. 2015;6:565–9) and (iii) to study the relationship between IP and frailty, functional dependence, advanced dementia and end-of-life situation. Setting Two nursing homes in the same geographical area in Catalonia (Spain). Method This was a prospective, descriptive and observational study of elderly nursing home residents. Each patient’s treatment was analysed by applying the PCP model, which centres therapeutic decisions on the patient’s global assessment and individual therapeutic goal. Main outcome measure Prevalence of polypharmacy and IP. Results 103 patients were included. They were characterized by high multimorbidity and frailty. Up to 59.2% were totally dependent. At least one IP was identified in 92.2% of residents. Prior to the pharmacological review, the mean number of chronic medications prescribed per resident was 6.63 (SD 2.93) and after this review it was 4.97 (SD 2.88). Polypharmacy decreased from 72.55% to 52.94% and excessive polypharmacy fell from 18.62% to 5.88%.The highest prevalence of IP was detected in people with a higher FI, in those identified as end-of-life, and also in more highly dependent residents (p < 0.05). Conclusions People who live in nursing homes have an advanced frailty. Establishing individualized therapeutic objectives with the application of the PCP model enabled to detect 92.2% of IP. People who are frailer, are functionally more dependent and those who are end-of-life are prescribed with inappropriate medication more frequently.

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Factors influencing safe glucose-lowering in older adults with type 2 diabetes: A PeRsOn-centred ApproaCh To IndiVidualisEd (PROACTIVE) Glycemic Goals for older people

Cited by 34 publications

References 113 publications

Diabetes and Frailty: An Expert Consensus Statement on the Management of Older Adults with Type 2 Diabetes

Diabetes and Frailty: An Expert Consensus Statement on the Management of Older Adults with Type 2 Diabetes

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

Therapeutic optimization through goal-oriented prescription in nursing homes

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