Medication deprescribing taking hold for oldest people with type 2 diabetes
medwireNews: Analysis of older people living in Denmark shows that doctors are increasingly deprescribing medications given solely to reduce blood glucose as people with type 2 diabetes near their end of life.
As well as becoming more common, deprescribing also started to occur earlier before death, report Vanja Kosjerina (Steno Diabetes Center Copenhagen, Denmark) and co-researchers, although they found it was “particularly pronounced” during the last year before death throughout the study period.
“Increased discontinuation rates during the last year of life indicate that recommendations to remove unnecessary medications in the context of short life expectancy are being adhered to,” the team writes in The Lancet Healthy Longevity.
The study included 52,523 people who died aged 80 years or older between 2006 and 2018, having had type 2 diabetes for a median of 9 years. Just over two-thirds of the participants had one or more diabetes complication at the time of death, most commonly cardiovascular, hypertensive, or kidney disease.
In 2006, 52% of people were taking any glucose-lowering medication at the time of their death; this fell to 38% in 2018. This was due to a reduced proportion of people taking one medication, with the proportion taking multiple medications remaining stable, at 7% and 8%, respectively.
Discontinuation of glucose-lowering medications was concentrated in the last year of life in all years of the study, but discontinuations earlier in a person’s late lifespan became more common in more recent years of the study.
Between 2006 and 2018, the proportion of people taking a sulfonylurea at the time of death “decreased substantially,” report the researchers.
By contrast, it became significantly more common for people to be taking metformin or a dipeptidyl peptidase (DPP)-4 inhibitor at the time of death, with use of the latter medication class increasing to nearly 10% between its introduction in 2008 and the end of the study period. End-of-life use of other new medication classes also increased, but only very slightly. End-of-life use of insulin remained relatively stable, in approximately 15% of people throughout the study.
The researchers note that while guideline updates may have contributed to decreasing use of glucose-lowering medications toward the end of life, lower glucose levels due to “sparse food intake” could also account for some deprescribing. And they add that efforts to protect failing kidneys might help explain the shift toward insulin and DPP-4 inhibitors, whose effects are independent of renal function.
In a linked commentary, Samuel Seidu and co-authors at the University of Leicester in the UK, describe the data as “very relevant,” given that “not many trend analyses have been published on de-prescribing” in older people.
But they add that more data are needed on people younger than 80 years, and on the impact of frailty.
The commentators add that when currently expensive medications become off-patent, they will be more widely used, and given their low risk for hypoglycemia, “[i]t is unclear whether de-intensification of these medications will be as clinically necessary as de-intensification of older medication types.”
They also point out that some newer medications classes may be classed as preventive, because of their protective effect on cardiovascular outcomes, or symptomatic, in the case of medications such as insulin, which rapidly reduce very high glucose levels, thereby reducing symptoms and improving quality of life.
“Further research is needed on which de-intensification approaches are appropriate and beneficial for specific patient populations,” Seidu and team conclude.
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