medwireNews: Researchers find that older adults with diabetes are frequently treated to an intensive glycemic target, putting them at risk for poor outcomes, particularly when high-risk agents are used.
Iliana Lega (Women’s College Hospital, Toronto, Ontario, Canada) and colleagues call their findings in their population-based cohort “worrisome, since the mean age was 80 years and individuals had a high burden of comorbidities.”
However, they also highlight the importance of accounting for frailty, which they say predicts poor outcomes better than age or comorbidities.
“As such, intensive glycaemic targets and high-risk agents should be particularly avoided in frail, older adults.”
The researchers studied 108,620 people who were aged at least 75 years and had received a prescription for one or more glucose-lowering medications from September 2014 through August 2015. All study participants had glycated hemoglobin (HbA1c) levels of 69 mmol/mol (8.5%) or less, as those with higher levels were considered likely to have additional risk factors for poor outcomes.
Of these people, 61.1% were defined as receiving treatment to an intensive glycemic target, because their HbA1c level was below 53 mmol/mol (7.0%), while 38.9% had a higher level and were therefore defined as having a conservative treatment target.
Around a third of the people treated to an intensive target (21.6% of the whole cohort) were receiving agents that carry a high risk for hypoglycemia, namely sulfonylureas or insulin.
The researchers note that this is despite guidelines of the time advising less stringent glycemic control for older people, especially those with comorbidities.
“Strategies for improving the dissemination and implementation of practice guidelines, such as communications campaigns, clinician and patient education, decision-support tools, audits and feedback are critical for aligning diabetes practice with recommendations for this vulnerable population,” they write in Diabetologia.
During the 30 days following the index HbA1c measurement, 0.92% of people receiving intensive control with high-risk agents required urgent or hospital treatment for a diabetes-related issue, including hypoglycemia, or died of any cause.
This compared with rates of 0.67% for those receiving conservative control with high-risk agents, 0.42% and 0.41% for those treated with low-risk agents to intensive and conservative targets, respectively.
In an analysis correcting for the propensity for being overtreated, there was a significant 49% increase in the risk for poor outcomes among people given intensive treatment with high-risk agents, when compared with conservative treatment with low-risk agents.
Intensive treatment per se was associated with an increased risk, reflected in a significant 25% increase for intensive versus conservative treatment with high-risk agents. But there was a larger risk increase, of 48%, for intensive control with high-risk versus low-risk agents.
This suggests “that the dangers of intensive control may be driven primarily by the use of high-risk agents for hypoglycaemia,” say the researchers.
Indeed, the risk for the secondary outcome of emergency department or hospital treatment for hypoglycemia was increased nearly sevenfold for intensive treatment with high-risk agents versus conservative treatment with low-risk agents.
“While the use of insulin may be appropriate in older adults in certain settings (e.g. reduced renal function, loss of secretory insulin capacity), clinicians need to use it with caution and aim for higher glycaemic targets in these settings,” observes the team.
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