Pilla SJ, Meza KA, Schoenborn NL, Boyd CM, Maruthur NM, Chander G. A Qualitative Study of Perspectives of Older Adults on Deintensifying Diabetes Medications [published online ahead of print, 2022 Sep 29]. J Gen Intern Med. 2022;10.1007/s11606-022-07828-3. doi:10.1007/s11606-022-07828-3
While previous studies have examined the patient perspective on deprescribing, few have explored this topic in relation to diabetes medications. Guidelines recommend deintensification of diabetes medications for older adults with type 2 diabetes who are below glycemic target where it can reduce polypharmacy or the risk of adverse drug effects. In practice, however, diabetes medications are rarely stopped or reduced regardless of glycemic control or health status. In hopes of optimizing deintensification, researchers at Johns Hopkins set out to understand the patient perspective on stopping or reducing diabetes medications. They conducted a qualitative study using individual semi-structured interviews of 24 older adults with medication-treated type 2 diabetes and good glycemic control. Interviewers sought participants’ perspectives on the appropriateness of deintensification, feelings and beliefs around deintensification, and the process of deintensification. Interviewers also explored participants’ response to deintensification in the context of clinical rationales using three hypothetical scenarios: poor health status, limited life expectancy, and high risk for hypoglycemia. Participant responses were organized into four themes:
Theme 1: Fear of losing control of diabetes
Participants expressed concerns about long-term and irreversible diabetes complications, the need to start insulin, and the drastic lifestyle changes that might be necessary to maintain their glycemic targets after stopping or reducing their diabetes medication.
Theme 2: Benefits of taking less medication
Participants who viewed deintensification favorably noted the lower risk of adverse drug reactions and fewer inconveniences associated with taking diabetes medications, but few considered the financial benefit of deintensification.
Theme 3: Anchoring to current diabetes treatment
Several participants were anchored to their current treatment plan, citing confusion about counterintuitive medical advice and the desire to avoid change at this stage of life. Participants also had misconceptions about diabetes treatment, including that deintensification would result in immediate harm or cause them to need insulin.
Theme 4: Influence of a trusting patient-provider relationship
Nearly every participant expressed trust in his or her provider as well as a desire to be involved in the decision to deintensify medication.
Most participants were in favor of deintensification in the context of high risk for hypoglycemia, but many expressed confusion about deintensification in the context of limited life expectancy or poor health status. Upon further discussion, they became more receptive to deintensification during end-of-life care and the concept of balancing medication-related benefits and harms. Overall, older adults communicated a high level of trust in their providers and were open to discussing deintensification, despite their reservations. Additional work is needed to educate older adults on individualized glycemic targets and the role of life expectancy in diabetes treatment. Primary author and former USDeN JII member Scott Pilla comments on next steps to promote the deintensification of diabetes medication:
“Many of the older adults in our study had tight diabetes control on high-risk medications, yet the idea of decreasing or stopping diabetes treatment was an unfamiliar and frightening concept. This shows how much work needs to be done to change perceptions about diabetes treatment such that deintensifying unnecessary medications is viewed as an accomplishment, and not something to be feared. Fortunately, older adults trust their doctors and want to discuss these issues, so the next step will be to help bring doctors and patients together and open channels of communication about deintensification. Progress in this area may come in many forms, including changing public messaging about diabetes control to emphasize individualized targets, improving providers’ training around deintensification, and empowering older adults through outreach in their health systems and communities.”