January 14, 2015
As we know, it takes a long time for the health care community to understand and embrace guidelines and new treatment paradigms. Once we finally get the snowball rolling down the hill it can be hard to change course or realize when a nuanced approach is needed. The ‘seven and under HbA1C’ guideline (as the threshold for demonstrating controlled diabetes) snowball has gathered momentum; all of the publicity around the diabetes epidemic in our young people, and its massive costs to the healthcare system have added to that momentum. But for our older patients with diabetes and complex co-morbidities, have we swung the pendulum too far?
In 2012, the ADA and AGS published a consensus statement endorsing higher HbA1C targets for some older patients as well as use of metformin as initial therapy for appropriate patients.. AGS had also updated the Beers Criteria to include an oral diabetes medication and certain strategies for insulin dosing as ‘potentially inappropriate’ for older adults. CMS has followed suit in their quality measures designating certain medications as ‘high risk’. But is anyone paying attention?
In a recent Journal of the American Medical Association Internal Medicine on-line publication (http://archinte.jamanetwork.com/article.aspx?articleid=2089233) researchers take on the task of advocating for individualized treatment plans for older adults with complex conditions and multiple co-morbidities. The lead author also shares personal thoughts on changing the approach to her own patients in a New York Times Op-Ed ( http://www.nytimes.com/2015/01/12/opinion/when-diabetes-treatment-goes-too-far.html?smid=nytcore-iphone-share&smprod=nytcore-iphone&_r=0).
The study “Potential Overtreatment of Diabetes Mellitus in Older Adults with Tight Glycemic Control” showed that roughly 60% of older adults with very complex to intermediate complex conditions had an A1C level of 7% or less, and that these patients were being treated with sulfonylureas or insulin. Despite this aggressive treatment, the health status of these patients did not markedly improve. The researchers concluded that “intensive glycemic control strategies markedly increase the risk of hypoglycemia, the results of which ( dizziness, fainting, etc) can have far more serious consequences in an older adult. Therefore, intensive strategies to lower glucose levels may result in more harm than benefit, particularly among older, sicker patients”.
Is it the tight control that is the issue, or is it the type of medications used to treat this specific cohort of patients and the consequent risks? In a response to the study, Dr. Alan Garber of the Baylor College of Medicine in Houston is quoted as saying that while “the traditional goals are perhaps too low…you have to try them on medications with a low risk of hypoglycemia”.
So, for our complex frail older patients with diabetes, it seems like we need to address both goals and treatment strategies when determining treatment plans. Let’s make sure we have reasonable HbA1C goals, and let’s also make sure we avoid hypoglycemic medications and dosage regimens that are known to predispose to hypoglycemia. We should actively interview our patients to make sure that how they are using their medications is not contributing to adverse medication events, and that they are not using ‘hidden’ medications or herbals/supplements that might also be causing harm. And finally, let’s assess risk on an individual basis, based on what we learn from the patient.
As lead author Dr. Kasia Lipska says in her New York Times piece, “The goal is not to get a perfect score on a report card, but to weigh these risks to make a good decision”.
Joseph Gruber, RPh, CGP, FASCP: Chief Clinical Officer, ActualMeds Corporation. Past President, American Society of Consultant Pharmacists. @jgactualmeds