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Older patients with diabetes are often overtreated

Physicians were not likely to cut back on BP and glycemic medication treatments in older patients with diabetes after they reach low BP or hemoglobin A1c levels, according to data recently published in JAMA Internal Medicine.

Researchers found that this practice was common despite guidelines from the American Diabetes Association, the American Geriatrics Society and the ABIM's Choosing Wisely campaign for less aggressive treatment.

Jeremy B. Sussman , MD, MS, a research scientist in the Center for Clinical Management Research at the Veterans Affairs Ann Arbor Health System, and colleagues noted that overtreatment can be harmful for patients.

"In the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study, providing treatment for patients with diabetes mellitus to achieve a target systolic BP of less than 120 mm Hg increased the rate of serious adverse events, and treating to a target HbA1c level of 6% increased all-cause mortality," they wrote. "Overtreatment is common even in older, medically complex patients, in whom it can be especially dangerous."

The researchers used data from the VA to conduct a retrospective cohort study between January 2012 and December 2012 of patients with diabetes aged at least 70 years. Participants were classified as receiving active treatment for BP control, which included hypertension medications other than low-dose angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, or active treatment for glucose level control, which included diabetes medications other than metformin hydrochloride.

Sussman and colleagues defined a need for deintensification of therapy when patients demonstrated low BP or low HbA1c levels, specifically systolic BP of 129 mm Hg or less, diastolic BP of 65 mm Hg or less, or HbA1c of 6.4% or less.

The researchers reported a BP cohort of 211,667 participants and an HbA1c cohort of 179,991 participants.

Results showed that among patients with a very low BP, 18.8% underwent deintensification, compared with 16% of patients with a moderately low BP and 15.1% of patients a BP classified as not low. Sussman and colleagues found that only 0.2% of patients with very low BP levels who did not have their treatment deintensified had an elevated follow-up measurement that was at least 140/90 mm Hg.

Additionally, among patients with a very low HbA1c, 27% underwent deintensification, compared with 20.9% of patients with a moderately low HbA1c and 17.5% of patients a HbA1c classified as not low. Less than 0.8% of patients with very low HbA1c levels who did not have their treatment deintensified had an elevated follow-up measurement that was at least 7.5%.

The researchers concluded that there was a weak association between deintensification and low BP or HbA1c levels.

"Health care professionals should assess the harms of intensive therapy just as they do the benefits," Sussman and colleagues stated. "These changes may require new clinical decision support tools, new performance measures, and, most important, a new perspective focusing on personalized, appropriate care." – by Chelsea Frajerman Pardes

Disclosures: The authors report no relevant financial disclosures.