Low rates of treatment deintensification following a severe hypoglycemic episode suggest discordance between guidelines and practice, according to the findings of a cohort study recently published in JAMA Network Open.

Although evidence-based guidelines recommend deintensification of sulfonylurea or insulin treatment in older patients following a hypoglycemic episode requiring hospital attention, current real-world deintensification practices are not well understood. This retrospective study aimed to determine the incidence of treatment deintensification in a real-world setting as well as identify factors associated with it.

The analysis included patients with diabetes who experienced at least 1 hypoglycemia-associated ED visit or hospitalization from a random sample of nationwide fee-for-service US Medicare beneficiaries between January 1, 2007, and December 31, 2017.

The primary endpoint of the study was the presence of sulfonylurea and/or insulin deintensification in the 100 days following a hypoglycemic episode requiring hospital attention. Treatment deintensification was defined as (1) decrease in a sulfonylurea dose, (2) change to a short-acting sulfonylurea from a long-acting one, or (3) discontinuation of a sulfonylurea or insulin (based on pharmacy dispensing claims).


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The analysis included 76,278 patients who experienced a total of 106,293 hypoglycemic episodes that required hospital attention. Of the total episodes, 30.2% (n=32,074) occurred in patients receiving a sulfonylurea only, 56.8% (n=60,350) occurred in patients receiving insulin only, and 13.0% (n=13,869) occurred in patients receiving sulfonylurea plus insulin.

“Treatment deintensification rates were highest among individuals receiving both sulfonylurea and insulin therapies at the time of their hypoglycemic episode (6677 episodes [48.1%]), followed by individuals receiving sulfonylurea only (14,192 episodes [44.2%]) and insulin only (14,495 episodes [24.0%]),” the study authors reported.

Between 2007 and 2017, an increase in treatment deintensification rates was observed, though rates remained below 50%. Lower rates of deintensification were seen among patients with lower socioeconomic status (sulfonylurea only: adjusted odds ratio [aOR], 0.74; 95% CI, 0.70-0.78); insulin only: aOR, 0.71; 95% CI, 0.68-0.75; sulfonylurea plus insulin: aOR, 0.72; 95% CI, 0.66-0.78).

Patient factors associated with higher rates of treatment deintensification included frailty, chronic kidney disease, history of falls, and depression.

“These results suggest that greater efforts are needed to identify individuals at high risk of hypoglycemia to encourage appropriate treatment deintensification in accordance with current evidence,” the authors concluded.

Disclosure: Some study authors declared affiliations with pharmaceutical companies. Please see the original reference for a full list of authors’ disclosures.  

Reference

Alexopoulos A, Kahkoska AR, Pate V, et al. Deintensification of treatment with sulfonylurea and insulin after severe hypoglycemia among older adults with diabetes. JAMA Netw. Open. Published online November 2, 2021. doi: 10.1001/jamanetworkopen.2021.32215.