medwireNews: Deintensifying diabetes treatment does not increase the risk for short-term adverse outcomes in male nursing home residents with limited life expectancy or advanced dementia, say researchers.
Joshua Niznik (VA Pittsburgh Healthcare System, Pennsylvania, USA) and colleagues say their study addresses “a major gap in evidence regarding optimal diabetes treatment for this population with medically complex conditions.”
The study cohort comprised 2082 men newly admitted to one of 133 nursing homes during 2009–2015 who had limited life expectancy or advanced dementia and were potentially overtreated for their diabetes, based on having a glycated hemoglobin (HbA1c) level of 7.5% (58 mmol/mol) or lower.
During the next 30 days, 27% of these men had their diabetes medications deintensified, defined as discontinuation or dose reduction of a noninsulin medication and/or discontinuation of a type of insulin, without an alternative glucose-lowering medication being prescribed in its place. The team did not assess changes in insulin dose, being unable to distinguish deliberate de-intensification from dose refinements in response to dietary changes and blood glucose measurements.
People who had their medication deintensified more often had HbA1c below 6.0% (42 mmol/mol) than those who did not (35.7 vs 23.2%), and more frequently used prandial insulin (67.7 vs 52.4%) or a sulfonylurea (37.0 vs 23.4%).
During the 60 days after treatment deintensification (or 30 days after the admission HbA1c test), 32.4% of the study participants had an adverse outcome, comprising 19.3% with hospital admissions, 9.3% with emergency department visits, and 3.9% who died.
After entropy balancing (similar to propensity-score matching), the researchers found no difference in the risk for hospital/emergency department admission or in the risk for death between men who did and did not have their diabetes medications de-intensified.
Writing in Diabetes Care, Niznik and team observe that it is desirable to reduce medication burden without increasing the risk for disease complications in people near end of life.
“Our findings support recommendations advocating for less aggressive HbA1c goals in adults with reduced life expectancy and suggest that deintensifying medications is an appropriate strategy to achieve these goals in this population,” they say.
The researchers believe it to be “highly unlikely” that deintensifying blood glucose management would increase the risk for adverse outcomes in the short term.
However, they caution: “It should be noted that prescribing patterns may have changed in the time since these data were collected, particularly for newer medications such as sodium–glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists that have lower risk of hypoglycemia and additional cardiovascular benefits.”
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