medwireNews: Older people with type 2 diabetes are more likely to receive inappropriately intensive glucose-lowering treatment if they live in high- versus middle income countries, show data from the global DISCOVER study.
Conversely, the study also revealed that, among those receiving inappropriate treatment, people from middle-income countries were more likely than those from high-income countries to be treated with drugs associated with a high-risk for hypoglycemia, specifically insulin, sulfonylureas, and meglitinides.
Brenda Bongaerts (German Diabetes Center Leibniz Institute for Diabetes Research at Heinrich Heine University, Düsseldorf) and colleagues say their findings highlight “the inequality of type 2 diabetes care across the globe and also the need for a more personalized approach to treatment of type 2 diabetes in older patients, with a greater consideration of the benefit to risk ratio of intensive glycemic control.”
The analysis included data for 3344 DISCOVER participants (23% of the full cohort) who were aged 65 years or older when initiating second-line glucose-lowering therapy at baseline.
Of these, 23.5% had a baseline glycated hemoglobin (HbA1c) level below 7.0% (53.0 mmol/mol) and therefore potentially received “inappropriate treatment intensification” according to the researchers.
The second-line treatments given to these well-controlled patients were classed as conferring a high risk for hypoglycemia in almost a third (32.1%) of cases.
During follow-up, the proportions with inappropriately tight HbA1c control increased to 55.2%, 54.2%, and 53.5% at 6, 12, and 24 months, respectively, with 35–36% of these individuals receiving high-risk medications.
Bongaerts and team report in BMJ Open Diabetes Research & Care that each US$ 5000 (€ 4157) increase in gross national income was associated with a significant 5% increased likelihood of having an HbA1c level below 7% at 12 months, and with a significant 14% decreased likelihood of being treated with insulin, sulfonylureas, and/or meglitinides.
The authors suggest that the more intensive glycemic control observed in high income countries may reflect “stricter treatment regimens, with a greater emphasis placed on glucose monitoring and achieving glycemic targets, and better access to healthcare.”
They also note that “increased prevalence of baseline vascular complications” in patients from high- versus lower-middle-income countries, as observed in a previous analysis of DISCOVER data, “may also play a part in driving the high rate of inappropriately intensively treated diabetes.”
Conversely, the greater use of high-risk medications in middle-income countries “may be indicative of the limited availability and affordability of alternative glucose-lowering therapies,” they say.
Bongaerts et al conclude: “Given the association between inappropriately intensive treatment and risk of hypoglycemia, there may be a need for some physicians to consider treatment regimen simplification (discontinuation of at least one glucose-lowering agent or a reduction in dosage) in some older patients, as per the current ADA guidelines.”
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