WHEN AND HOW TO DEINTENSIFY TYPE II DIABETES

CARE

Carole E. Aubert, Illiana C Lega, Olivier Bourron, Alice J Train,

Jeffrey T kullgren
BMJ: 2021
  Antidiabetic treatment → Delay the progression
of T2DM long term complications
 Diabetes over treatment may harm some
patients (e.g elderly patients with many
comorbidities, frails)

 Tight glycemic control in elderly patients with many

comorbidities→ increase risk of complication in elderly
 Observational study of elderly patient with T2DM: tight blood control
(hbA1c < 7%) results in increased risk of falls, severe hypoglicemia,
emergency department visits, hospitalizations and death
Deintensification (reducing meds or dosages): loosening blood glucose
control targets and other measures → decrease the burden of diabetetes
monitoring and complication in elderly patients

Benefits of
deidensifications strategy

This article discuss about

The ways to reaching
individual and sharing
management plans
Clinical Vignette
 A 77 year old woman diagnosed with T2DM for 15 years and
she was on metformin and Gliklazid
 She also takes regular medication for hypertension, atrial
fibrilation, heart failure, osteoporosis and CKD
 Lives alone and receives daily home care
 History of hospital admission after a fall and head injury that
resulted in a subdural hematoma
 Rarely leave the house → afraid of falling
 Random blood glucose= 2.7 mmol/L, HbA1c 7.4%
 Problems
 HbA1c was 7.4% with intermediate health status
( multiple comorbidities, cognitive and functional
impairment)
 Higher risk medication of hypoglicemia ( Gliclazide)
 Risk of faster cognitive decline and adverse medical
and social consecuences
 Social withdrawal
 Burdersome over-monitoring of home blood glucose

Patients Goals
 Reduce blood glucose monitoring and risk of
hypoglicemia
 Regain confidence and be able to go outside of home
again
Identifying candidate  Deintensification → Help patient to adress the
for deintensification problems and achieve the goals
 The risk of maintaining the patients HbA1c < 7.5%
likely exceed the benefits to her

Discussing
deintensification  Ask the patient to include her daughter in the discussion
 Explain the risks of continuing with current medication and
treatment target
 identify the best option for the patient
 Explain that if she chooses to stop taking gliclazide, home
glucose monitoring can be stopped since the remaining
medication (metformin) do not cause hypoglycaemia
 Use shared decision making techniques
 Use the SURE questionnaire to evaluate patient confidence
 Implementing  Plan:
deintensification - Stop sulfonylurea, continue metformin
- Stop monitoring if patient feels safe
- deprescribe other medications
 Chech HbA1c after 3 months and discuss deprescribing
further antidiabetics if needed
 What is good practice in frail older adults
with T2DM ?
There is no evidence to support tight glycaemic control among
frail older adults with multiple comorbidities, dementia or
limited expectancy
 Manajement should be based on the condition of each patients

Routine assement of elderly

patient with T2DM  Complication of DM
 Psychological, functional , social and
geriatic function
 How to identify candidates for deintesfication

Deintensfication of DM care:
 Loosening blood glucose or HbA1c
target and other parameters
 We have to consider the patien’s
preferences, values, sosial
contexts, benefits, harms, costs
and incovinence of different
management options
 How to identify candidates for deintesfication
 Assess the patient’s state of health → prevent effect of tight glycemic
control
 How to Deintensify diabetes care
Deprescribing antidiabetic drugs, reducing home blood glucose monitoring,
deprescribing other medication, reducing diabetes-specific assessments

Deprescribing  Stopping or reducing the dose (start with the Higher risk
antidiabetic of hypoglicemia ec sulfonilurea/insulin)
 Swithing to another drug with a lower risk for
hypoglicemia (metformin/DPP-4 inhibitor)

Guidline for deprescibing antidiabetic in older adults (Canadian

Group):
 Daily monitoring for 1-2 weeks after deprescribing
 Increasing blood glucose monitoring (glucose blood perifer)
 How to Deintensify diabetes care

Reducing home
blood glucose
monitoring  Excessive home monitoring→ increased cost and
discomfort

We suggest stopping home blood glucose monitoring for patients are not taking
sulfonylurea or insulin (except patient with significant eythrocyte turnover disorder)
 How to Deintensify diabetes care

Deprescribing other
 BP goals in patients with poor health (Target BP < 150/90
medications
mmHg)
 Choose antihypertensive based on comorbidies and
patiens side effect
 Consider to stopping lipid-lowering medication in patient
with poor medical condition

Reducing diabetes-
specific treatments
 Patients in paliative care/ severe debility/advanced
dementia → all T2DM specific assements that do not
promote comfort can be discontinued
How to conduce conversations to individualise
diabetes care?
● Approach patient centered decision
making→ responsive to individual
patient’s preference, needs and
values
● Neutral language,explain the potential
benefits and harms of each option
● Deintesification to reduce patient
harm → excessive treatment and
monitoring
● Be Open about your own concers
 Make sure the patient understands the options and impact of treatment and
how confident they feel about their decision

PASTI21 4-item questionare

• Sure of myself—“Do you feel sure about the best choice for
you?”
• Understanding information—“Do you know the benefits and
risks of each option?”
• Risk-benefit ratio—“Are you clear about which benefits and
risks matter most to you?”
• Encouragement—“Do you have enough support and advice to
make a choice?”
 Thanks!
Do you have any questions?

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