medwireNews: Less than a quarter of patients with low glycated hemoglobin (HbA1c) levels have their diabetes therapy deintensified, even though previous studies have shown increased mortality associated with intense glycemic control.
“Overtreatment of glycemia is not harmless: it markedly increases the risk of hypoglycemia, and treatment to achieve target HbA1C levels around 6% increased all-cause mortality in the ACCORD Study,” Finlay McAlister (University of Alberta, Edmonton, Canada) and co-authors remark.
In the current study, the researchers retrospectively reviewed data from 99,694 individuals aged 20 years and older (mean 54 years) who were being actively treated for new diabetes between 2004 and 2009. Most patients (82.9%) were receiving one or two glucose-lowering medications, and the majority (77.3%) were relatively healthy. In addition, 10.6% had multiple comorbidities, and 12.0% met the researchers’ definition for frailty.
After 1 year, 13.0% of individuals had an HbA1c level below 6%, 19.7% a level between 6.0% and 6.4%, 35.1% had a level between 6.5% and 7.5%, and 32.2% had an HbA1c level above 7.5%.
Overall, 18.3% of patients had their glycemic therapy deintensified after their index HbA1c measurement.
There was a clinically small, but statistically significant, variation in the rate of deintensification across HbA1c strata, at 20.6% for individuals with HbA1c below 6%, and 17.3%, 17.7%, and 18.6% for those with levels between 6.0% and 6.4%, 6.5% and 7.5%, and above 7.5%, respectively.
There were also small but significant differences by health status, with deintensification more common among frail patients (21.2%) and those with multiple comorbidities (19.4%) than those who were relatively healthy (17.7%).
And despite concerns about the safety of intense glycemic control being raised by the ACCORD trial in 2008, the proportion of patients with deintensified therapy has fallen significantly, from 22.5% before 2008 to 19.5% after.
Editorialists Sridharan Raghavan and Daniel Matlock, both from the University of Colorado School of Medicine in Aurora, USA, say: “This study adds to the growing body of work describing diabetes mellitus overtreatment and suggests that overtreatment is an unrecognized problem across the spectrum of patients with diabetes mellitus.”
They add: “Provider inertia, patient satisfaction with care, and the tendency for healthcare preferences to default to the status quo all favor treatment continuation.”
In addition, McAlister et al suggest that primary care providers may be “more concerned about negative repercussions from deintensifying therapy (not meeting performance targets and medicolegal ramifications) than the potential harms of tight control.”
Writing in Circulation: Cardiovascular Quality and Outcomes, they conclude: “Increased attention to the potential hazards of overtreatment will improve physician awareness of this issue, but deintensification of long-term therapy is the next frontier for improving care quality.”
By Laura Cowen
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