Intensive Glycemic Control in the Elderly: Is It Time to Rethink the Standard Approach?
The authors of a recent study said using intensified glycemic control as the standard for treating older individuals with type 2 diabetes is a failure in patient care and challenged pharmacists to instead focus on individualized dosing that reduces the burdens of living with the disease.
“Pharmacists need to look beyond the Physicians’ Desk Reference to information from trials to assess the specific impact of therapies and share that information with patients,” said study lead author Dr. Sandeep Vijan, of the Ann Arbor Veterans Affairs Health Services Research and Development Center for Clinical Management Research. “Dosing needs to move away from predetermining standardized glucose goals for all patients.”
He made that challenge based on simulated patient models that assessed how lowering HbA1C levels impacted diabetes treatment and, perhaps more importantly in the eyes of the researchers, patients’ quality-adjusted life years (QALYs). The models showed reducing HbA1c levels by a single percentage point improved QALYs from 0.77 to 0.91 in patients who received initial treatment at 45 years of age and from 0.08 to 0.10 in patients who began treatment at 75 years of age. According to the study, increasing the disease burden by 0.01 in older patients negated the benefits of lowering HbA1c levels. Additionally, treatment viewed by patients as only slightly more burdensome resulted in overall net harm.
The researchers conceded that controlling glycemic levels provides considerable benefits in younger patients, but the overall advantages become less significant as patients age, especially when the treatment’s end result is often influenced by the patient’s perception of its success. For example, the study estimated that lowering the HbA1c level by 1 percentage point in a 75-year-old patient would result in 22 more days of quality living. Would the patient consider that worth suffering through potential weight gain, hypoglycemia, and gastrointestinal issues?
Dr. Vijan recommended that pharmacists ensure patients truly understand the benefits and drawbacks of the medications they are considering, including the side effects, potential adverse events, and what the therapy actually entails.
“Far too often, providers dictate treatment goals from a set standard — targeting HbA1c less than 7%, for example — and simply prescribe a drug without involving patients in the decision-making process,” he explained. “Our study clearly showed that this is likely to result in aggressive therapy for people who wouldn't want the treatment if they were fully informed and able to participate in the treatment discussion.”
For example, said Dr. Vijan, insulin causes weight gain, but patients are rarely warned of that side effect. “For the majority of patients, how they feel about the burdens of taking these medications is more important than the glucose lowering effect in determining overall quality of life,” he added.
Dr. Vijan suggested pharmacists ensure patients have discussions with their physicians about how much benefit they’ll receive from intensified efforts to manage glucose levels. “Many older patients won’t benefit from intensive therapy once they reach moderate control, so they get only side effects and treatment burdens,” he commented. “Patients — and many providers — don't know this, but it should be made clear.”
The study was published online in JAMA Internal Medicine.
—Dan Cook
Reference:
1. Vijan S, Sussman JB, Yudkin JS, Hayward RA. Effect of patients’ risks and preferences on health gains with plasma glucose level lowering in type 2 diabetes mellitus. JAMA Intern Med. 2014 Jun 30. [Epub ahead of print]
