Abstract
To assess deintensification approaches and rates and evaluate the harm and benefits of deintensification with antidiabetic medication and other therapies among older people (≥ 65 years) with type 2 diabetes with or without cardiometabolic conditions. We identified relevant studies in a literature search of MEDLINE, Embase, Web of Science and Cochrane databases to 30 October 2018. Data were extracted on baseline characteristics, details on deintensification and outcomes, and was synthesized using a narrative approach. Ten studies (observational cohorts and interventional studies) with data on 26 558 patients with comorbidities were eligible. Deintensification approaches included complete withdrawal, discontinuation, reducing dosage, conversion, or substitution of at least one medication, but the majority of studies were based on complete withdrawal or discontinuation of antihyperglycaemic medication. Rates of deintensification approaches ranged from 13.4%-75%. The majority of studies reported no deterioration in HbA1c levels, hypoglycaemic episodes, falls or hospitalizations on deintensification. On adverse events and mortality, no significant differences were observed among the comparison groups in the majority of studies. Available but limited evidence suggests that the benefits of deintensification outweigh the harm in older people with type 2 diabetes with or without comorbidities. Given the heterogeneity of patients with diabetes, further research is warranted on which deintensification approaches are appropriate and beneficial for each specific patient population.
Highlights
Type 2 diabetes is a chronic disease which is characterized by high levels of blood glucose
Deintensification approaches included complete withdrawal, discontinuation, reducing dosage, conversion, or substitution of at least one medication, but majority of studies were based on complete withdrawal or discontinuation of antihyperglycaemic medication
Key findings Using a systematic review, we have assessed deintensification approaches and rates and the associated benefits and harms from available published observational and interventional studies conducted in older people with type 2 diabetes, including those with comorbidities such as coronary heart disease (CHD), hypertension, and kidney disease
Summary
Type 2 diabetes is a chronic disease which is characterized by high levels of blood glucose (hyperglycaemia). Deintensification as defined by a position statement from Primary Care Diabetes Europe, is the de-escalation or down-titration of glucoselowering therapy by reducing the dose, deprescribing or substituting one agent for a less potent glucose-lowering therapy.[23] Deintensification includes deprescribing, which is the process of withdrawal or stopping inappropriate medication and the ultimate goal is improving outcomes and managing polypharmacy.[24,25] Deintensification approaches are on the increase and it is becoming an established part of the prescribing process, especially in the management of older patients with multiple comorbidities.[26,27] There is emerging evidence on the efficacy of deintensification from several randomised trials and observational studies conducted in other patient populations.[25] In older patients with type 2 diabetes with or without comorbidities, it is uncertain whether the benefits of deintensification outweighs the harms in these patients In this context, using a systematic review of all available published observational and interventional evidence, our primary aim was to assess deintensification approaches and rates and evaluate the harms and benefits of deintensification with antidiabetic medication and other therapies amongst older people (≥ 65 years) with type 2 diabetes with or without other cardiometabolic conditions such as CVD, CKD, or dementia.
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