Who benefits from having treatment deintensified?

Diabetes makes a great case study for deintensification, because patients often need treatment over the course of a lifetime. For decades, doctors have focused on treating diabetes intensively to lower their patients’ risks of developing kidney disease and other complications. But we now know that intensive treatment for diabetes, like nearly all medical treatments, can have also cause serious harm, such as low blood sugar levels, which can lead to falls and memory problems, and even death.

Many patients with diabetes may benefit from deintensification. Older patients, in particular, are more likely to experience drug side effects, and patients taking more than one medicine run a risk of harmful drug interactions. Older patients also have less to gain from intensive treatment of their diabetes because they have fewer years to develop the long-term effects of diabetes on their bodies. And as a person’s health status changes, they may need fewer – not more – medicines to manage their diabetes.

That doesn’t mean intensive treatment is bad – it just means that not every patient needs it, and some patients may need it for only a certain amount of time. For example, intensive treatment to lower blood sugar in younger people lowers their risk of developing kidney and eye disease, and other harmful long-term effects of diabetes.

So drug choices need to be individualized based on what a person stands to gain from intensive treatment, balanced against their risk of treatment side effects. Deintensifying treatment means finding the sweet spot between too much and too little medicine.

Even though many clinical practice guidelines already recognize that goals for diabetes control and other chronic conditions should be based on a patient’s individual risk and benefits of treatment, this message hasn’t gotten through to all doctors and patients. And none of these guidelines specify who should have treatment deintensification and when that should happen.