Diabetes management can be quite complex as it is a progressive disease, and goals can change depending on a variety of patient factors. In general, the ADA suggests an A1C goal of <7%, but in some cases, less stringent goals like <8% may be appropriate. The assessment and reassessment of goals and management techniques need to be done frequently. Let’s discuss some situations where less stringent goals are appropriate and when to de-escalate diabetes medications
High Hypoglycemia Risk
Medications like insulin, sulfonylureas, and meglitinides (rarely used) have a higher risk of hypoglycemia compared to other agents. De-escalating, switching to a lower risk medication, or using less stringent treatment goals are necessary for patients with severe or frequent hypoglycemia. Low hypoglycemia risk drugs include GLP-1 agonists, metformin, SGLT2 inhibitors, or DPP4 inhibitors, and are good choices for this subset of patients.
Severe or Life-limiting Comorbidities
End-stage organ failure, advanced malignancies, or other terminal diseases should be a major consideration for reassessing diabetes goals. In this population, it is important to consider quality of life and comfort over intensive glucose control.
Older Adults
This population is at a higher risk for cognitive/functional impairment and hypoglycemia. They also may be more frail and have serious comorbidities (hypertension, CKD, malnutrition, etc.) that make strict management hard to attain and put them at greater risk of the consequences of hypoglycemia (falls, fractures, cognitive decline, hospitalizations, etc.). Using higher goals may be more beneficial in this population to improve quality of life and reduce burden of treatment.
Cognitive or Functional Impairment
Patients with these conditions may struggle to adhere to medications and/or have impaired hypoglycemia awareness, putting them at risk for serious complications. The Institute for Healthcare Improvement developed an evidence-based 4M’s framework that approaches diabetes management through assessment of Medications, Mentation, Mobility, and What Matters most to help health systems address patient-specific issues affecting diabetes management.
Long Duration of Diabetes
Some studies suggest there is an element of metabolic memory/legacy effect where finite intensive glucose-lowering has extended benefits that last after therapy is de-escalated. Evidence from trials like the ADVANCE, ACCORD, and VADT found that intensive glucose control did not reduce CVD events, and hyperglycemia is a weak predictor of CVD compared to blood pressure and lipids. In fact, hypoglycemia itself is a more immediate risk than high glucose, and avoiding this should be prioritized over aggressively attempting to reach goals in those who cannot safely achieve them. This population usually has established vascular disease, and intensive control may take years to provide benefit, but increase risk of hypoglycemia. Healthcare providers should always be reassessing treatment goals and regimens against patient needs and risks.
There are other situations in which a de-escalation of diabetes medications may be necessary, including but not limited to treatment with pharmacotherapy that don’t have benefits outside of glycemic control, food insecurity, and metabolic surgery. It is important to continuously assess patients’ goals of care, weigh risks vs benefits, and consider the indications, effectiveness, safety, and convenience of all medications, especially high-risk medications (insulin, sulfonylureas, etc).
This article was written by Maddie Detra, PharmD Candidate, in collaboration with Eric Christianson, PharmD, BCPS, BCGP.
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