Sulfonylurea, insulin deintensification lags behind recommendations
medwireNews: Fewer than half of older adults receiving a sulfonylurea and/or insulin have their treatment deintensified after an emergency department (ED) visit or hospitalization for hypoglycemia, despite guidelines recommending this practice, US research shows.
“Although there was a pattern of increasing sulfonylurea and/or insulin deintensification over a 10-year period, low overall rates of deintensification suggest that real-world practice may lag behind evidence that positions severe hypoglycemia as a major health and safety concern among older adults,” write Anastasia-Stefania Alexopoulos (Duke University, Durham, North Carolina) and co-authors in JAMA Network Open.
Alexopoulos and team used Medicare data to identify 76,278 people aged 65 years and older (mean 76.6 years) with diabetes who had at least one hypoglycemia-associated ED visit or hospitalization between 2007 and 2017.
Of the 106,293 total hypoglycemic episodes recorded, 30.2% were among individuals receiving a sulfonylurea only, 56.8% were among those receiving insulin only, and 13.0% occurred among those receiving both drugs.
The researchers report that, overall, 44.2% of people receiving a sulfonylurea had their treatment deintensified within 100 days following the hypoglycemia event, compared with 24.0% of those receiving insulin only and 48.1% of individuals receiving both a sulfonylurea and insulin.
They also observed that the deintensification rates increased slightly with time, from 41.4% to 49.7% between 2007 and 2017 for sulfonylurea monotherapy, from 21.3% to 25.9% for insulin monotherapy, and from 45.9% to 49.6% for combined therapy.
Several baseline variables were associated with either an increased or decreased likelihood of deintensification.
For example, lower socioeconomic status (defined by the receipt of low-income subsidies) was associated with a significant 26% to 29% lower odds of deintensification, regardless of baseline treatment regimen.
Individuals receiving angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, or statins were also significantly less likely to have each of the treatment categories deintensified than people not on these medications, “which suggests that patients with diabetes complications that were being managed more aggressively were less likely to experience treatment deintensification,” Alexopoulos et al remark.
Conversely, chronic kidney disease, a history of falls, and depression were each independently linked to an increased probability of deintensification, with adjusted odds ratios ranging from a significant 1.06 to 1.50 across the three treatment groups.
“All of these comorbidities are associated with a markedly high risk of severe hypoglycemia, suggesting that health care professionals may identify and act upon high-risk clinical phenotypes, including those that would be most affected by the sequelae of hypoglycemia,” the investigators say.
They also note that 11.5% of the cohort died within the 100 days of their hypoglycemic episode, which “is consistent with existing knowledge that suggests an association between severe hypoglycemia and all-cause mortality, and it underscores the importance of hypoglycemia avoidance in this population.”
Alexopoulos and team conclude that their findings “suggest a need for enhanced recognition of individuals at high risk for recurrent hypoglycemic episodes as well as efforts to combat clinical inertia associated with treatment deintensification in this setting.”
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