A National Physician Survey of Deintensifying Diabetes Medications for Older Adults With Type 2 Diabetes

Abstract

Objective: To determine physicians' approach to deintensifying (reducing/stopping) or switching hypoglycemia-causing medications for older adults with type 2 diabetes.

Research design and methods: In this national survey, U.S. physicians in general medicine, geriatrics, or endocrinology reported changes they would make to hypoglycemia-causing medications for older adults in three scenarios: good health, HbA1c of 6.3%; complex health, HbA1c of 7.3%; and poor health, HbA1c of 7.7%.

Results: There were 445 eligible respondents (response rate 37.5%). In patient scenarios, 48%, 4%, and 20% of physicians deintensified hypoglycemia-causing medications for patients with good, complex, and poor health, respectively. Overall, 17% of physicians switched medications without significant differences by patient health. One-half of physicians selected HbA1c targets below guideline recommendations for older adults with complex or poor health.

Conclusions: Most U.S. physicians would not deintensify or switch hypoglycemia-causing medications within guideline-recommended HbA1c targets. Physician preference for lower HbA1c targets than guidelines needs to be addressed to optimize deintensification decisions.

Graphical abstract

Figure 1

Physicians’ modifications to sulfonylureas or insulin therapy for patients who reported no hypoglycemia or medication concerns in three clinical scenarios. Scenarios described older adults with type 2 diabetes taking a hypoglycemia-causing medication with HbA_1c below guideline-recommended targets. Scenario 1 was a healthy patient with an HbA_1c of 6.3% taking glimepiride. Scenario 2 was a patient with complex health and an HbA_1c of 7.3% taking insulin glargine. Scenario 3 was a patient with poor health and an HbA_1c of 7.7% taking glipizide.

Figure 2

Effect of patient characteristics and preference on physicians’ modifications to sulfonylureas or insulin therapy in clinical scenarios. Shown is the percentage of physicians deintensifying (reducing or stopping), switching, or making no change or increasing the medication in all three clinical scenarios combined. The first bar shows the base case where the patient reported no recent hypoglycemia or medication concerns, followed by each listed variation. Increasing the medication was uncommon (<3%) except where the patient desired tight control (12% increased). Physicians’ actions for mild hypoglycemia (three episodes within the past month of mild symptoms and blood glucose 55–65 mg/dL) and severe hypoglycemia (confusion requiring family assistance) were similar to hypoglycemia causing somnolence resulting in an emergency department visit (data not shown).

Figure 3

Physicians’ selection of HbA_1c target for older adults with type 2 diabetes in relation to ADA guidelines. Patients in good, complex, and poor health were described using the language in the ADA Standards of Medical Care in Diabetes—2022 section on older adults (2). Guideline-concordant HbA_1c targets were <7.0 to 7.5% (good health), <8.0% (complex health), and <8.5% or no specific target (poor health).