medwireNews: Less than a third of nursing home residents who meet the criteria for overtreatment of type 2 diabetes have their treatment deintensified, suggests an analysis of Veterans Affairs data.
“Based on our study results, it will be important to develop deprescribing initiatives in [nursing homes] at time of admission that use behavior change principles to overcome prescribing inertia in overtreated residents,” write Lauren Lederle (University of California, San Francisco, USA) and co-authors in the Journal of the American Geriatrics Society.
The study included data for 7422 people aged 65 years and older (mean 75 years, 98% men) with type 2 diabetes who were newly admitted to a Veterans Affairs (VA) nursing home and had a length of stay of at least 30 days between 2013 and 2019.
The researchers chose this period because it “represents a time when clinicians review medications in light of the new [nursing home] resident's goals of treatment.”
At their index glycated hemoglobin (HbA1c) measurement, the majority (65.6%) of participants showed tight glycemic control (HbA1c <7.5%; 58 mmol/mol) and most (66.8%) were on insulin.
Furthermore, 17% of participants met the criteria for overtreatment (HbA1c <6.5%; 48 mmol/mol with any insulin) and 23% met criteria for potential overtreatment (HbA1c <7.5% with any insulin use or <6.5% on any glucose-lowering medication other than metformin monotherapy).
Treatment was deintensified, typically through discontinuation of short-acting insulin or reduction of a long-acting insulin dose, within 14 days of the index HbA1c measurement for 27% of overtreated residents and 19% of potentially overtreated residents.
Of note, a respective 12% and 15% had their treatments intensified, with the remaining 61% and 66% maintaining the same regimens.
After adjustment for potential confounders, the investigators observed that long-acting insulin use and hyperglycemia at or above 300 mg/dL (16.65 mmol/L) before index HbA1c were associated with a significantly increased likelihood of continued overtreatment at odds ratios (ORs) of 1.37 and 1.35, respectively.
Conversely, severe functional impairment (Minimum Data Set-Activities of Daily Living score ≥19) was associated with decreased odds of continued overtreatment (OR=0.73).
And although at least one episode of hypoglycemia (≤70 mg/dL; 3.9 mmol/L) was recorded in 31.7% of the cohort before their index HbA1c measurement, it was not associated with decreased odds of overtreatment – a finding the authors describe as “alarming.”
They say: “Reducing the risk of hypoglycemia is an important goal of diabetes deintensification,” and therefore propose that nursing home residents “with an episode of hypoglycemia should be required to undergo a medication review.”
Older age, increased comorbidity burden, and cognitive impairment were also not associated with a reduced risk for overtreatment.
Lederle and team conclude: “Many [nursing home] residents who are unlikely to benefit from tight glycemic control and are at high risk of hypoglycemia continue to receive insulin and other medications that increase hypoglycemia risk even after HbA1c results suggest overtreatment.”
The add: “The fact that diabetes factors such as hyperglycemia were associated with continued overtreatment while resident characteristics such as cognitive impairment were not associated with continued overtreatment suggests that clinicians may focus more on the characteristics of the ‘disease’ rather than the person in glycemic treatment decisions.”
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