Medication deintensification in older patients with low HbA1c or blood pressure

Among older patients with diabetes whose treatment has resulted in very low hemoglobin A1c (HbA1c) levels or blood pressure values, only 27 percent or fewer underwent medication deintensification, a lost opportunity to reduce overtreatment, according to an article published online by JAMA Internal Medicine.

New guidelines and the Choosing Wisely campaign recommend less aggressive treatment for older patients and those with limited life expectancy, such as a target HbA1c level of 7.5 percent or 8.0 percent. Another report recommends older patients seek to achieve a systolic blood pressure (SBP) of 150 mm Hg and no longer try to reach a level below 140 mm Hg. However, little is known about the process of medication deintensification, including how often it happens and for whom.

Jeremy B. Sussman, M.D., M.S., of the Veterans Affairs Center for Clinical Management Research, Ann Arbor, Mich., and coauthors describe the frequency of medication deintensification among older adults with diabetes using data from the U.S Veterans Health Administration. Participants included 211,667 patients older than 70 receiving active treatment in 2012. Active treatment was defined as blood pressure-lowering medications other than angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, or glucose-lowering medications other than metformin hydrochloride.

More than half of the 211,667 participants actively treated for blood pressure had moderately low (SBP of 120 to 129 mm Hg or diastolic blood pressure [DBP] less than 65 mm Hg) or very low (SBP less than 120 mm Hg or DBP less than 65 mm Hg) blood pressure levels. Treatment was deintensified in 16 percent of the 25,955 patients with moderately low blood pressure levels and in 18.8 percent of the 81,226 patients with very low blood pressure levels. Of the patients with very low blood pressure levels whose treatment was not deintensified, only 0.2 percent had a follow-up blood pressure measurement that was elevated (≥ 140/90 mm Hg), according to the results.

The actively treated HbA1c group included 179,991 individuals. Treatment was deintensified in 20.9 percent of the 23,769 patients with moderately low HbA1c (6.0 percent to 6.4 percent) levels and in 27 percent of the 12,917 patients with very low HbA1c (less than 6.0 percent). Of the patients with very low HbA1c whose treatment was not deintensified, fewer than 0.8 percent had a follow-up elevated HbA1c (≥ 7.5 percent), the results indicate.

The authors acknowledge several reasons why low blood pressure or HbA1c levels have a weak association with medication deintensification. Those reasons include requiring a shift in how treatment is understood by patients and explained by health care professionals. Also, guidelines and performance measures are more focused on preventing underuse than overuse.

“Future performance management systems should consider how to create incentives against both overuse and underuse to motivate appropriate treatment, including deintensification of treatment that is personalized to individual needs, risks and benefits. In addition, health care professionals should assess the harms of intensive therapy just as they do the benefits. These changes may require new clinical decision support tools, new performance measures and, most important, a new perspective focusing on personalized, appropriate care,” the authors conclude.

Research Letter: Appropriate Prescribing for Patients with Diabetes

A research letter Tanner J. Caverly, M.D., M.P.H., of the Ann Arbor Veterans Affairs Center for Clinical Management Research, Michigan, and coauthors examined the beliefs of primary care health-care professionals (PCPs) as to how receptive they might be to recommendations for limiting medications for some older patients, including a hypothetical scenario involving a 77-year-old man with diabetes at risk for hypoglycemia. The authors surveyed Department of Veterans Affairs PCPs, including physicians, nurse practitioners and physician assistants. Of 1,222 eligible PCPs, 594 returned usable surveys. The results indicate that almost half of the PCPs reported that they would not worry about the harms of tight glycemic control for an older patient at risk for hypoglycemia. Nearly one-quarter of PCPs reported they would worry that deintensifying medication for the man in the hypothetical situation could leave them vulnerable to future 26
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