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. 2020 Feb;8(1):e001007.
doi: 10.1136/bmjdrc-2019-001007.

Paradox of Glycemic Management: Multimorbidity, Glycemic Control, and High-Risk Medication Use Among Adults With Diabetes

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Free PMC article

Paradox of Glycemic Management: Multimorbidity, Glycemic Control, and High-Risk Medication Use Among Adults With Diabetes

Rozalina G McCoy et al. BMJ Open Diabetes Res Care. .
Free PMC article

Abstract

Introduction: Glycemic targets and glucose-lowering regimens should be individualized based on multiple factors, including the presence of comorbidities. We examined contemporary patterns of glycemic control and use of medications known to cause hypoglycemia among adults with diabetes across age and multimorbidity.

Research design and methods: We retrospectively examined glycosylated hemoglobin (HbA1c) levels and rates of insulin/sulfonylurea use as a function of age and multimorbidity using administrative claims and laboratory data for adults with type 2 diabetes included in OptumLabs Data Warehouse, 1 January 2014 to 31 December 2016. Comorbidity burden was assessed by counts of any of 16 comorbidities specified by guidelines as warranting relaxation of HbA1c targets, classified as being diabetes concordant (diabetes complications or risk factors), discordant (unrelated to diabetes), or advanced (life limiting).

Results: Among 194 157 patients with type 2 diabetes included in the study, 45.2% had only concordant comorbidities, 30.6% concordant and discordant, 2.7% only discordant, and 13.0% had ≥1 advanced comorbidity. Mean HbA1c was 7.7% among 18-44 year-olds versus 6.9% among ≥75 year-olds, and was higher among patients with comorbidities: 7.3% with concordant only, 7.1% with discordant only, 7.1% with concordant and discordant, and 7.0% with advanced comorbidities compared with 7.4% among patients without comorbidities. The odds of insulin use decreased with age (OR 0.51 (95% CI 0.48 to 0.54) for age ≥75 vs 18-44 years) but increased with accumulation of concordant (OR 5.50 (95% CI 5.22 to 5.79) for ≥3 vs none), discordant (OR 1.72 (95% CI 1.60 to 1.86) for ≥3 vs none), and advanced (OR 1.45 (95% CI 1.25 to 1.68) for ≥2 vs none) comorbidities. Conversely, sulfonylurea use increased with age (OR 1.36 (95% CI 1.29 to 1.44) for age ≥75 vs 18-44 years) but decreased with accumulation of concordant (OR 0.76 (95% CI 0.73 to 0.79) for ≥3 vs none), discordant (OR 0.70 (95% CI 0.64 to 0.76) for ≥3 vs none), but not advanced (OR 0.86 (95% CI 0.74 to 1.01) for ≥2 vs none) comorbidities.

Conclusions: The proportion of patients achieving low HbA1c levels was highest among older and multimorbid patients. Older patients and patients with higher comorbidity burden were more likely to be treated with insulin to achieve these HbA1c levels despite potential for hypoglycemia and uncertain long-term benefit.

Keywords: diabetes; evidence-based medicine; insulin; intensive control; intensive treatment; multimorbidity; overtreatment; patient-centered care; risk treatment paradox; sulfonylurea.

Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
Glycemic control and sulfonylurea use in the context of advanced age and multimorbidity. Shown are the proportions of patients within each hemoglobin A1c (HbA1c) category treated with sulfonylurea (no insulin) as a function of (A) age, (B) Charlson index, (C) number of concordant comorbidities among patients with only concordant comorbidities, (D) number of discordant comorbidities among patients with only discordant comorbidities, (E) number of concordant and/or discordant comorbidities among patients with both, and (F) total number of comorbidities among patients with at least one advanced illness, with or without concurrent concordant and/or discordant conditions.
Figure 2
Figure 2
Glycemic control and insulin use in the context of advanced age and multimorbidity. Shown are the proportions of patients within each hemoglobin A1c (HbA1c) category treated with insulin (with or without sulfonylurea) as a function of (A) age, (B) Charlson index, (C) number of concordant comorbidities among patients with only concordant comorbidities, (D) number of discordant comorbidities among patients with only discordant comorbidities, (E) number of concordant and/or discordant comorbidities among patients with both, and (F) total number of comorbidities among patients with at least one advanced illness, with or without concurrent concordant and/or discordant conditions.

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