Background: Older adults with diabetes are less likely to benefit and more likely to be harmed by intensive glucose control. Prior research has shown that many older adults continue to be intensively managed despite guidelines that recommend that treatment targets should be relaxed in these patients. As many new agents have been introduced with minimal risk of hypoglycemia, we examined contemporary data to understand to what extent older patients with diabetes are still intensively managed with agents that can cause hypoglycemia.
Methods: We examined A1c and treatment data in adults ≥75 years with type 2 diabetes from 151 US outpatient sites in DCR. Patients were categorized as poor control (A1c >9%), moderate control (A1c >8-9%), conservative control (A1c 7-8%), tight control/low-risk agents (A1c <7% on meds with low risk for hypoglycemia), and tight control/high-risk agents (A1c <7% on insulin, sulfonylureas, or meglitinides). Adults with A1c <7% on no glucose-lowering medications were excluded. We used hierarchical logistic regression to examine patient and site factors associated with tight control/high-risk agents vs. conservative control or tight control/low-risk agents.
Results: Among 30,696 older adults with diabetes, 5,596 (18%) had moderate or poor control, 9,227 (30%) conservative control, 7,893 (26%) tight control/low-risk agents, and 7,980 (26%) tight control/high-risk agents (Fig. A). Older age, male sex, heart failure, chronic kidney disease, and coronary artery disease were each independently associated with a greater odds of tight control/high-risk agents (Fig. B). After adjusting for patient factors, there were no differences among practice specialties (endocrinology, primary care, cardiology) in how aggressively patients were managed.
Conclusion: Despite greater availability of agents that do not cause hypoglycemia, a quarter of older adults with type 2 diabetes are tightly controlled with high-risk medications. These results suggest potential overtreatment of a substantial proportion of patients. Efforts are needed to provide more specific guidance on how to safely treat older adults with diabetes (both through targeting treatment with low-risk agents and through de-escalation of glucose control) and then to efficiently translate that guidance into busy clinical practice.