Type 2 diabetes treatment paradox still apparent in the USA
medwireNews: Older patients with type 2 diabetes and multiple comorbidities continue to achieve lower glycated hemoglobin (HbA1c) levels, often while on insulin, than their younger, healthier counterparts, despite guideline advice to the contrary, US researchers report.
“Clinical practice guidelines advise against pursuit of low glycemic targets, and caution with use of insulin and sulfonylureas, among patients with complex and very complex health status, as doing so exposes patients to risk of hypoglycemia without yielding meaningful improvements in health outcomes,” write Rozalina McCoy (Mayo Clinic, Rochester, Minnesota) and colleagues in BMJ Open Diabetes Research & Care.
Yet they found that mean HbA1c decreased with age and was lower in people with versus without comorbidities in their analysis of US registry data for 194,157 patients (mean age 66 years, 51% women) with type 2 diabetes.
The study “therefore reinforces the age and comorbidity-driven risk/treatment paradox in glucose-lowering therapy,” they say.
Just 8.5% of the study participants had none of the 16 comorbidities specified by guidelines as warranting relaxation of HbA1c targets; 45.2% had only concordant comorbidities (ie, diabetes complications or risk factors), 2.7% had only discordant (ie, unrelated to diabetes), 30.6% had concordant and discordant comorbidities, and 13.0% had at least one advanced (life-limiting) comorbidity.
Mean HbA1c was 7.4%, 7.3%, 7.1%, 7.1%, and 7.0% in these five groups, respectively.
After adjusting for factors including sex, race/ethnicity, income, and HbA1c level, the researchers found that people with three or more concordant comorbidities were 5.50 times more likely to be insulin users than those with none; for discordant comorbidities, the increased odds was 1.72-fold, while people with two or more advanced comorbidities were 1.45 times more likely to be using insulin than those with none.
Regarding age, mean HbA1c was 7.7%, 7.5%, 7.1%, and 6.9% among people aged 18–44, 45–64, 65–74, and 75 years and older, respectively, with insulin use decreasing with increasing age, such that people in the oldest age group were 49% less likely to be insulin users than those in the youngest age group in adjusted analyses.
By contrast, the odds of sulfonylurea use increased with age but decreased with greater multimorbidity. In this case the oldest patients were 1.36 times more likely to be sulfonylurea users than the youngest ones, whereas people with three or more concordant or discordant comorbidities were 24% and 30% less likely to use this drug class, respectively, than those with no comorbidity.
McCoy et al conclude: “Our study suggests ample opportunity for insulin deintensification among older patients and patients with advanced and/or multiple comorbidities, which may lower their risk of hypoglycemia.
“Conversely, younger and healthier patients may benefit from treatment intensification and addressing of barriers to optimal diabetes control.”
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