Inappropriate intensification of glucose-lowering treatment in older patients with type 2 diabetes: the global DISCOVER study

• Main Authors: Jesús Medina, Peter Fenici, Fengming Tang, Hirotaka Watada, Antonio Nicolucci, Iichiro Shimomura, Mikhail Kosiborod, Hungta Chen, Andrew Cooper, Brenda Bongaerts, Bernard H Charbonnel, Marilia Gomes, Marina Shestakova
• Format: Article
• Language: English
• Published: BMJ Publishing Group 2021-08-01
• Series: BMJ Open Diabetes Research & Care
• Online Access: https://drc.bmj.com/content/9/1/e001585.full

Introduction Although individualized target glycated hemoglobin (HbA1c) levels are recommended in older people with type 2 diabetes, studies report high levels of potential overtreatment. We aimed to investigate the proportion of older patients (aged ≥65 years) who potentially received an inappropriately intensive treatment (HbA1c level <7.0% (53.0 mmol/mol)) in a global study. Factors associated with intensive glycemic management and using glucose-lowering medications associated with a high risk of hypoglycemia (high-risk medications (insulin, sulfonylureas, and meglitinides)) were also assessed.Research design and methods DISCOVER is a 3-year observational study program of 15 992 people with type 2 diabetes initiating second-line glucose-lowering therapy in 38 countries. Data were collected at baseline (initiation of second-line therapy) and at 6, 12, and 24 months. Factors associated with an inappropriately intensive treatment or using high-risk medications were assessed using a hierarchical regression model.Results Of the 3344 older patients with baseline HbA1c data in our analytic cohort, 23.5% received inappropriate treatment intensification. Among those who had follow-up HbA1c data, 55.2%, 54.2%, and 53.5% were inappropriately tightly controlled at 6, 12, and 24 months, respectively, with higher proportions in high-income than in middle-income countries. The proportion of patients receiving high-risk medications was higher in middle-income countries than in high-income countries. Gross national income (per US$5000 increment) was associated with increased odds of inappropriately intensive treatment but with decreased odds of receiving high-risk medications.Conclusions A large proportion of older DISCOVER patients received an inappropriately intensive glucose-lowering treatment across the 2 years of follow-up, with substantial regional variation. The use of high-risk medications in these patients is particularly concerning.