Overtreatment of older patients with type 2 diabetes mellitus in primary care

Hart, Huberta E.; Rutten, Guy E.H.M.; Bontje, Kyra N.; Vos, Rimke C.

doi:10.1111/dom.13174

Cited by 28 publications

(45 citation statements)

References 8 publications

(9 reference statements)

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“…The prevalence of polypharmacy regimen, defined as the use of more than 5 medications, increases with age. Results from a Dutch study revealed that 64 persons (20%) out of 319 type 2 diabetic patients aged ≥70 years were overtreated and frail (38). Furthermore, one-quarter of US older diabetic adults are on potential overtreatment for tight glycemic control using glucose-lowering medications at high risk of hypoglycemia (39).…”

Section: Diabetes and Geriatric Syndromesmentioning

confidence: 99%

Diabetes and Aging: From Treatment Goals to Pharmacologic Therapy

et al. 2019

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Diabetes is becoming one of the most widespread health burning problems in the elderly. Worldwide prevalence of diabetes among subjects over 65 years was 123 million in 2017, a number that is expected to double in 2045. Old patients with diabetes have a higher risk of common geriatric syndromes, including frailty, cognitive impairment and dementia, urinary incontinence, traumatic falls and fractures, disability, side effects of polypharmacy, which have an important impact on quality of life and may interfere with anti-diabetic treatment. Because of all these factors, clinical management of type 2 diabetes in elderly patients currently represents a real challenge for the physician. Actually, the optimal glycemic target to achieve for elderly diabetic patients is still a matter of debate. The American Diabetes Association suggests a HbA1c goal <7.5% for older adults with intact cognitive and functional status, whereas, the American Association of Clinical Endocrinologists (AACE) recommends HbA1c levels of 6.5% or lower as long as it can be achieved safely, with a less stringent target (>6.5%) for patients with concurrent serious illness and at high risk of hypoglycemia. By contrast, the American College of Physicians (ACP) suggests more conservative goals (HbA1c levels between 7 and 8%) for most older patients, and a less intense pharmacotherapy, when HbA1C levels are ≤6.5%. Management of glycemic goals and antihyperglycemic treatment has to be individualized in accordance to medical history and comorbidities, giving preference to drugs that are associated with low risk of hypoglycemia. Antihyperglycemic agents considered safe and effective for type 2 diabetic older patients include: metformin (the first-line agent), pioglitazone, dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 receptor agonists. Insulin secretagogue agents have to be used with caution because of their significant hypoglycemic risk; if used, short-acting sulfonylureas, as gliclazide, or glinides as repaglinide, should be preferred. When using complex insulin regimen in old people with diabetes, attention should be paid for the risk of hypoglycemia. In this paper we aim to review and discuss the best glycemic targets as well as the best treatment choices for older people with type 2 diabetes based on current international guidelines.

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Section: Diabetes and Geriatric Syndromesmentioning

confidence: 99%

Diabetes and Aging: From Treatment Goals to Pharmacologic Therapy

et al. 2019

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“…28 In line with the concept of quaternary prevention-avoidance of overmedicalization in at-risk populations 29 , the definition of adequate glycaemic control should be revised in those vulnerable patients along with the promotion of the safest drugs, instead of insulin or SUs. Overtreatment in older diabetic patients is quite common and should be avoided in order to prevent harmful consequences such as falls resulting from hypoglycaemia.…”

Section: Discussionmentioning

confidence: 99%

“…Overtreatment in older diabetic patients is quite common and should be avoided in order to prevent harmful consequences such as falls resulting from hypoglycaemia. 28 In line with the concept of quaternary prevention-avoidance of overmedicalization in at-risk populations 29 , the definition of adequate glycaemic control should be revised in those vulnerable patients along with the promotion of the safest drugs, instead of insulin or SUs. In our study, we excluded patients with preintensification HbA1c values <7%, to minimize the possibility of overtreatment.…”

Section: Discussionmentioning

confidence: 99%

Glycaemic control after treatment intensification in patients with type 2 diabetes uncontrolled on two or more non‐insulin antidiabetic drugs in a real‐world setting

Canivell

Mata-Cases

Real

et al. 2019

Diabetes Obesity Metabolism

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Aim: To assess glycaemic control after treatment intensification in patients with type 2 diabetes uncontrolled on ≥2 non-insulin antidiabetic drugs (NIADS).Methods: A retrospective cohort study, using electronic health records from the SIDIAP database (2010-2014), was conducted. Intensification was defined as the prescription of any new antidiabetic drug in patients treated with ≥2 NIADS and HbA1c >7%. The primary outcome was the absolute change in HbA1c 6-12 months after any intensification. Secondary analyses included the percentage of patients reaching HbA1c <7%, HbA1c <8%, and a reduction of HbA1c >1% after the first intensification.Results: There were 21 241 intensifications in 15 205 patients with a mean (SD) HbA1c of 9.02% (±1.35). Insulin and dipeptidyl peptidase-4 inhibitors (DPP4i) were the most frequently added therapies. The mean baseline-adjusted HbA1c reduction was 0.78% (95% CI, −0.80 to −0.76), varying from −0.69% with DPP4i to −0.85% with glucagon-like peptide-1 receptor agonists while the addition of insulin was associated with a reduction >1%.After the first intensification, 48.9% of patients achieved HbA1c <8%, 16.2% HbA1c <7%, and 43.1% a reduction >1%. High previous HbA1c was positively associated with the reduction of HbA1c >1% [odds ratio (OR) 2.13 (95% CI: 2.05-2.21)], but inversely associated with the attainment of HbA1c <7% [OR 0.64 (0.61-0.67)] or < 8% [OR 0.63 (0.60-0.65)]. Older age, male gender, higher Charlson index, and short diabetes duration were associated with achievement of HbA1c <7%.Conclusions: Despite intensification, most patients failed the glycaemic goal of HbA1c <7%. The reduction depended mainly on preintensification HbA1c values, with small differences between drugs. K E Y W O R D Sglycaemic control, intensification, observational, type 2 diabetes mellitus *Both authors contributed equally to this work.

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“…Important points are avoiding overly intensive diabetes management and using therapies with a low risk of hypoglycaemia, as recommended by both the ADA and the Dutch College of General Practitioners [9, 20]. In clinical practise, de-intensifying glucose lowering treatment is not yet successfully implemented [21, 22].…”

Section: Discussionmentioning

confidence: 99%

People with type 2 diabetes and screen-detected cognitive impairment use acute health care services more often: observations from the COG-ID study

Janssen

Koekkoek

Biessels

et al. 2019

Diabetol Metab Syndr

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Background Patients with type 2 diabetes have an increased risk of cognitive impairment which can lead to impaired diabetes self-management and an increased risk of diabetes-related complications. Routine screening for cognitive impairment in elderly patients with type 2 diabetes is therefore increasingly advocated. The aim of this study is to investigate whether people with type 2 diabetes and screen-detected cognitive impairment use acute health care services more often than patients not suspected of cognitive impairment. Methods People with type 2 diabetes ≥ 70 years were screened for cognitive impairment in primary care. Diagnoses in screen positives were established at a memory clinic. Information about acute health care use was collected for 2 years prior to and 2 years after screening and compared to screen negatives. Results 154 participants (38% female, mean age 76.7 ± 5.2 years, diabetes duration 8.7 ± 8.2 years) were included, 37 patients with cognitive impairment, 117 screen negatives. A higher percentage of participants with cognitive impairment compared to screen negative patients used acute health care services; this difference was significant for general practitioner’s out of hours services (56% versus 34% used this service over 4 years, p = 0.02). The mean number of acute health care visits was also higher in those with cognitive impairment than in screen negatives (2.2 ± 2.8 versus 1.4 ± 2.2 visits in 4 years, p < 0.05; 1.4 ± 2.2 versus 0.7 ± 1.5 visits in 2 years after screening, p = 0.03). Factors that could have played a role in this increased risk of acute health care services use were a low educational level, the presence of depressive symptoms (CES-D score ≥ 16), self-reported problems in self-care and self-reported problems in usual activities. Conclusions People with type 2 diabetes and screen-detected cognitive impairment use acute health care services more often. Electronic supplementary material The online version of this article (10.1186/s13098-019-0416-z) contains supplementary material, which is available to authorized users.

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Overtreatment of older patients with type 2 diabetes mellitus in primary care

Cited by 28 publications

References 8 publications

Diabetes and Aging: From Treatment Goals to Pharmacologic Therapy

Diabetes and Aging: From Treatment Goals to Pharmacologic Therapy

Glycaemic control after treatment intensification in patients with type 2 diabetes uncontrolled on two or more non‐insulin antidiabetic drugs in a real‐world setting

People with type 2 diabetes and screen-detected cognitive impairment use acute health care services more often: observations from the COG-ID study

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