Overly aggressive treatment of blood sugar in older people with diabetes can harm — but a new study finds it’s still common.
Anyone with diabetes who takes medication to control blood sugar knows their doctor prescribed it for a reason. After all, the long-term effects of elevated blood sugar can harm everything from the heart and kidneys to the eyes and feet.
But what if stopping or cutting back on those drugs could help even more in some patients?
In some older patients, such "de-intensification" of diabetes treatment may be the safer route, because of the risk of falls and other problems that accompany low blood sugar.
A new study in the Journal of General Internal Medicine suggests that more doctors and such patients should work together to dial back diabetes treatment when necessary.
"By focusing on both overtreatment and undertreatment ends of the diabetes quality spectrum, we can best begin to improve the quality of diabetes care in all respects, ensuring that patients get needed care while avoiding unnecessary potential harm," says Jeremy Sussman, M.D., M.S., a co-author of the study and an assistant professor of general internal medicine at the University of Michigan. He is also a researcher at the VA Ann Arbor Healthcare System.
Doctors often treat diabetes with an eye toward long-term effects, but Sussman and his colleagues write that effective treatment requires a personalized approach based on individual risk and benefit.
Patterns of overtreatment
The study examined detailed records from 78,792 Medicare participants with diabetes who were 65 and older and lived in 10 states.
Almost 11 percent had very low ongoing blood sugar levels recorded during the study period, suggesting overtreatment. But only 14 percent of that subgroup had a reduction in blood sugar medication refills in the six months after that reading.
Patients 75 and older, as well as those who qualified for both Medicare and Medicaid because of low income or serious disability, were most likely to be overtreated, the study found. Hispanics and those who lived in urban areas were less likely.
Patients over 75 were less likely than others to have their treatment dialed back, as measured by prescription doses and refills.
But patients who had more than six chronic conditions, or who lived in urban areas or had frequent outpatient visits, were more likely to have their medication dialed back.
Results were compiled by researchers from Duke University, the University of Michigan and the VA hospitals in Durham, North Carolina, and Ann Arbor, Michigan.
The authors, led by Duke/Durham researcher Matthew Maciejewski, Ph.D., warn against a one-size-fits-all approach to treating diabetes in older patients.
Instead, they advise greater personalized care that accounts for the risks and benefits that such treatment holds for each patient.
Sussman, also a member of the U-M Institute for Healthcare Policy and Innovation and the VA Center for Clinical Management Research, says that older patients with diabetes — and the adult children who often assist with their care — should talk to their care teams about whether de-intensification is right for them.
It can be hard for an older person to recognize the signs of too-low blood sugar, such as confusion and combativeness, or of too-low blood pressure, such as dizziness.
Elderly patients can also struggle to keep up with multiple medications and frequent blood sugar checks. De-intensifying their treatment can often provide relief.
Long-term gain, short-term pain
If a patient has been on medication for diabetes for many years and is in their late 70s or older, they may have had many long-term benefits from keeping their levels in control.
Controlling these factors for years can help people cut their risk of problems that result from too-high sugar levels, such as stroke, heart attack, blindness, nerve damage, amputation and kidney failure.
Because the chances of a dangerous dip in blood sugar or blood pressure increase with age, however, the short-term risk starts to eclipse any long-term gains.
"Every guideline for physicians has detailed guidance for prescribing and stepping up or adding drugs to control these risk factors, and somewhere toward the end it says, 'Personalize treatment for older people,'" says Sussman. "But nowhere do they say actually stop medication in the oldest patients to avoid hypoglycemia or too-low blood pressure."
For elderly individuals, very low blood sugar levels — called hypoglycemia — can raise the risk of dizzy spells, confusion, falls and even death.
Which is why more experts are suggesting that doctors ease up on how aggressively they treat such patients for high blood pressure or diabetes, especially when the patient has other conditions that limit life expectancy.
But it rarely occurs: A previous study by Sussman and his U-M/VA colleagues showed that only 1 in 4 of nearly 400,000 older patients in the VA system who could have been eligible to ease up on their blood sugar medicines actually had their dosage changed.
Even those with the lowest readings or the fewest years to live had only a slightly greater chance than other patients of having their treatment de-intensified.
The VA system is trying to encourage de-intensification of blood sugar-reducing treatment in its oldest patients nationwide. The U-M/Ann Arbor VA team, led by Eve Kerr, M.D., M.S., is examining the effects of that effort.
More about the study
For the study, the team looked at prescription refills among patients whose blood sugar readings — represented by a measure called HbA1c — were well below recommended levels.
They focused on patients who had an A1c at or below 6.5 percent at a single point in 2011 and those with an A1c greater than 9, which is considered very high.
In practice, patients with A1c levels lower than 6.5 would be eligible to ease up on their blood sugar medication dosages to lower their risk of hypoglycemia.
It also could help dictate what doctors prescribe to treat them: The American Geriatrics Society recommends that the only medication an older person with diabetes should be on if they have an A1c level below 7.5 percent is metformin.
While 10.9 percent of the Medicare participants in the study were being overtreated to the point of an ultra-low A1c level, only 6.9 percent were being undertreated and had A1c levels over 9.
"The oldest Medicare beneficiaries are the least likely to benefit from tight glycemic control and most likely to be harmed, so it is troubling that they were more likely to be overtreated and less likely to have their medication regimens de-intensified," Sussman says.
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