Is type 2 diabetes mellitus appropriately treated in multimorbid elderly patients? Sources of potential overtreatment.
(2020) Spring Congress of the Swiss Society of General Internal Medicine — Location: Basel (CH)
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- Introduction: In multimorbid older patients with type 2 diabetes mellitus (T2DM), the intensity of glucose-lowering therapy (GLT) should balance the opposing risks of hypoglycemia under a more stringent regimen and end organ damage under less stringent control. In multimorbid patients, the harm of treating T2DM according to target guidelines may outweigh the benefits, and thus the current guidelines recommend focusing on avoiding side effects than attaining a specific HbA1c level. Methods: In a multicentre European study of multimorbid older patients (OPERAM, “Optimising PharmacothERApy in the Multimorbid elderly”), we evaluated HbA1c levels and GLT in T2DM participants. Participants were aged ≥70 years, with multimorbidity (≥3 chronic diagnoses), and polypharmacy (≥5 chronic medications), enrolled in four university centres across Europe (Switzerland, Belgium, Netherlands, Ireland). We regarded multimorbid older participants receiving GLT with an HbA1c <7% as potentially overtreated and >9% as undertreated. Results: Among 1938 multimorbid older patients (mean age 78±6 years, 38% women, Charlson comorbidity index 7±2), 564 (27%) had T2DM. Seventy-four (13%) diabetic participants had no GLT with a mean HbA1c of 6.5±0.8%, while the remaining 490 (87%) diabetic participants were on GLT achieving a mean HbA1c of 7.3±1.3%. Among these treated diabetic participants, 226 patients (46%) were potentially overtreated and 37 patients (8%) were undertreated. Among T2DM patients on GLT with an HbA1c <7% (mean 6.2±0.5%), Metformin (65%) was the most frequently used pharmacotherapy, followed by insulin (27%) and sulfonylureas (25%), and 41% were prescribed two or more glucose-lowering agents. Among T2DM patients with an HbA1c >9% (mean 10.3±0.9%), 70% were on insulin, 46% on metformin and 32% on sulfonylureas, and 81% were prescribed two or more glucose-lowering drugs. Conclusions: Our findings suggest that a much higher proportion of multimorbid older patients with T2DM is potentially over- than undertreated, and thus may incur a substantial risk of hypoglycemia. Therefore, GLT including insulin, sulfonylureas and multiple glucose-lowering agents, should be critically reviewed in multimorbid older patients with T2DM and HbA1c levels <7% in order to reduce inappropriate polypharmacy leading to higher risk of side effects.
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Baretella, O., Papazoglou, D., Feller, M., Christiaens, A., Meinders, A., Byrne, S., Kearny, P., O’Mahony, D., Knol, W., Boland, B., Aujesky, D., & Rodondi, N. (2020). Is type 2 diabetes mellitus appropriately treated in multimorbid elderly patients? Sources of potential overtreatment. Spring Congress of the Swiss Society of General Internal Medicine, Basel (CH). https://hdl.handle.net/2078.5/112466