Less than one-third of older adults with diabetes whose treatment resulted in very low HbA1c levels or blood pressure values underwent medication deintensification, missing an opportunity to reduce overtreatment, an article published in JAMA Internal Medicine reported.
The Choosing Wisely campaign and new guidelines recommend less aggressive treatment for older adults and those with limited life expectancy such as a target HbA1c 7.5% or 8.0%. Another report recommends older patients achieving a systolic blood pressure of 150mmHg instead of <140mmHg.
Researchers from the Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, utilized data from the U.S. Veterans Health Administration (n=211,667) to examine the frequency of medication deintensification among older patients with diabetes. Patients aged ≥70 years receiving active therapy in 2012 were included in the analysis. Active treatment was defined as blood-pressure lowering medications that were not angiotensin-converting enzyme inhibitors or angiotensin receptor blockers; and glucose-lowering medications that were not metformin HCl.
Over half of the patients actively treated for blood pressure had moderately low (systolic 120-129mmHg or diastolic <65mmHg) or very low (systolic <120mmHg or diastolic <65mmHg) blood pressure levels. Treatment deintensification was seen in 16% of the patients with moderately low blood pressure levels (n=25,955) and in 1.8% of the patients with very low blood pressure levels (n=81,226). Only 0.2% of patients with very low blood pressure levels who did not have treatment deintensification had follow-up blood pressure that was elevated ≥140/90mmHg.
Among patients with moderately low HbA1c (6–6.4%; n=23,769), treatment was deintensified in 20.9% of the patients, and in 27% of patients with very low HbA1c (<6%; n=12,917). Less than 0.8% of patients with very low HbA1c who did not have treatment deintensification had follow-up HbA1c that was elevated (≥7.5%).
Study authors concluded that future management systems should “consider how to create incentives against both overuse and underuse to motivate approrpriate treatment, including deintensification.” Some changes may require new clinical decision support tools and performance measures, they added.
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