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

Abstract

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.

Barriers and Enablers of Healthcare Providers to Deprescribe Cardiometabolic Medication in Older Patients: A Focus Group Study

“…Deprescribing comprises the systematic reduction or withdrawal of medication that may cause harm or no longer contributes to an individuals' health status [13,14]. Deprescribing of glucose-lowering medication in patients with comorbidity, frailty, hypoglycemic risk, or a limited life expectancy seems feasible and safe [8,15,16]. Furthermore, deprescribing of antihypertensive medication in frail older patients seems appropriate and feasible [7,17].…”

Expert Panel Guidance and Narrative Review of Treatment Simplification of Complex Insulin Regimens to Improve Outcomes in Type 2 Diabetes

“…A literature review was undertaken to analyse the treatment landscape with respect to articles addressing simplification of complex insulin regimens. The results suggested that the need to simplify treatment is mostly recognised in older individuals and those with comorbidities [24,[34][35][36][37][38][39]. Data from older populations suggest simplification of treatment can be achieved in these people with good glycaemic control.…”

“…In a real-world, prospective, single-arm clinical trial of older individuals with T2D, treatment simplification reduced the risk of hypoglycaemia and diabetes-related stress, without compromising glycaemic control [36]. However, little guidance and scarce data are available regarding non-elderly groups [24,[34][35][36][37][38][39].…”

When and how to deintensify type 2 diabetes care

“…There is little evidence to guide deprescribing of drugs to lower blood pressure or blood lipid levels in older patients with type 2 diabetes,15 and guidelines vary on this point. Blood pressure goals can be relaxed to <150/90 mm Hg in patients in poor health 781617.…”

“…Decision aids and a typology classification of patients according to their attitudes towards medications and involvement in care may be useful for this purpose (box 3). 151920…”