Few Have Medications Reduced, Despite Hypoglycemia

By Brenda L. Mooney

DURHAM, NC—It’s not only the VA that struggles with the balance between just enough treatment of older Type 2 diabetes patients and too much.

A new study involving VA researchers found that more than 1 in 10 Medicare patients with diabetes had very low blood sugar, suggesting possible overtreatment. Yet, the report in the Journal of General Internal Medicine, adds, very few of them reduced refills of glucose-lowering medications over the next six months.1

Deintensification of diabetes treatment is necessary in those patients to avoid falls and other risks of too-low blood sugar, study authors emphasized.

Researchers from VAMCs in Durham, NC, and Ann Arbor, MI, as well as Duke University and the University of Michigan, found that nearly 11% of Medicare beneficiaries had very low blood sugar, with hemoglobin A1c under 6.5%. Yet, based on pharmacy information, only 14% percent of them appeared to reduce their diabetes medication.

Most likely to be overtreated were patients older than 75 and those who qualified for both Medicare and Medicaid because of low incomes or serious disability. Less likely to be overtreated were patients who lived in urban areas or were of Hispanic origin.

Patients older than 75 also were less likely to have their treatment de-intensified, study authors noted. At the same time, patients who had more than six chronic conditions or who lived in urban areas or had frequent outpatient visits were more likely to experience a reduction in glucose-lowering drugs.

Included in the study were detailed records from 78,792 Medicare participants diagnosed with Type 2 diabetes in 10 states. The authors cautioned against a “one-size-fits-all” approach when treating diabetes in older patients and urge more personalized care.

“Every guideline for physicians has detailed guidance for prescribing and stepping up or adding drugs to control these risk factors, and somewhere toward the end it says ‘personalize treatment for older people,’” explained co-author Jeremy Sussman, MD, a University of Michigan assistant professor of general internal medicine and VA Ann Arbor researcher. “But nowhere do they say actually stop medication in the oldest patients to avoid hypoglycemia or too-low blood pressure.”

A previous study by Sussman and colleagues showed that only 1 in 4 of nearly 400,000 older patients in the VA system who could have been eligible to ease up on their blood sugar medicines actually had their dosage changed.

Even those with the lowest readings or the fewest years left to live had only slightly greater chance as other patients of having their treatment deintensified.

That study published online by JAMA Internal Medicine in 2015 found that too many older patients with very low HbA1c or blood pressure levels continue to be overtreated in the VHA.2

In fact, only 27% or fewer of older patients treated at the VHA had their medications reduced, despite very low HbA1c or blood pressure levels, according to some of the same researchers involved in the current study.

Another study published at that time helped explain the reluctance to reduce diabetes medication. Despite a VA campaign to raise awareness of hypoglycemia and recommendations from the national Choosing Wisely campaign to less aggressively treat older patients with limited life expectancy, almost half of the VA primary care providers responding to a survey said they would not be concerned about the harms of tight glycemic control for a hypothetical 77-year-old man with diabetes.

In fact, nearly one-quarter of the respondents said they were more worried that de-intensifying medication for the man in the hypothetical situation—with a hemoglobin A1c (HbA1c) of 6.5%, high risk for hypoglycemia, severe kidney disease and prescribed glipizide 10 mg, twice daily—could leave them vulnerable to future malpractice claims.3

  1. Maciejewski ML, Mi X, Sussman J, Greiner M, Curtis LH, Ng J, Haffer SC, Kerr EA. Overtreatment and Deintensification of Diabetic Therapy among Medicare Beneficiaries. J Gen Intern Med. 2017 Sep 13. doi: 10.1007/s11606-017-4167-y. [Epub ahead of print] PubMed PMID: 28905179.
  2. Sussman JB, Kerr EA, Saini SD, Holleman RG, Klamerus ML, Min LC, Vijan S, Hofer TP. Rates of Deintensification of Blood Pressure and Glycemic Medication Treatment Based on Levels of Control and Life Expectancy in Older Patients With Diabetes Mellitus. JAMA Intern Med. 2015 Oct 26:1-8. doi: 10.1001/jamainternmed.2015.5110. [Epub ahead of print] PubMed PMID: 26502220.
  3. Caverly TJ, Fagerlin A, Zikmund-Fisher BJ, Kirsh S, Kullgren JT, Prenovost K, Kerr EA. Appropriate Prescribing for Patients With Diabetes at High Risk for Hypoglycemia: National Survey of Veterans Affairs Health Care Professionals. JAMA Intern Med. 2015 Oct 26:1-3. doi: 10.1001/jamainternmed.2015.5950. [Epub ahead of print] PubMed PMID: 26502113.