Cookie policy: This site uses cookies (small files stored on your computer) to simplify and improve your experience of this website. Cookies are small text files stored on the device you are using to access this website. For more information please take a look at our terms and conditions. Some parts of the site may not work properly if you choose not to accept cookies.

Join

Subscribe or Register

Existing user? Login

Medicines optimisation

Doctors reluctant to reduce medication even when blood sugar may be dangerously low

Patients aged over 70 years with low blood sugar or blood pressure are being overtreated because clinicians are reluctant to alter their medication.

Older patients with diabetes whose blood sugar or blood pressure may be dangerously low are being overtreated because clinicians are reluctant to change their medication. In the image, a doctor speaks with an elderly female patient

Source: Phanie / Alamy Stock Photo

Stopping a patient’s medication requires a change in how clinicians explain treatment, with a greater focus on the balance of risks and benefits 

Older patients with diabetes whose blood sugar or blood pressure (BP) may be dangerously low are being overtreated because clinicians are reluctant to change medication in this group of patients, according to the results of two studies published in JAMA Internal Medicine[1].

Both studies focused on patients aged over 70 years with type 1 or type 2 diabetes whose blood sugar and BP were controlled with medication.

In the first study, researchers from the University of Michigan, Ann Arbor, analysed the records of 211,667 patients. They found that treatment was “deintensified” in 18.8% of patients identified with very low BP (defined as less than 120/65mmHg) and 16.0% of patients with moderately low BP (systolic BP 120-129mmHg or diastolic BP less than 65mmHg). In patients with very low BP whose medication remained the same, only 0.2% had raised BP at a follow-up check.

Some 20.9% of patients whose HbA1c levels were moderately low had their treatment changed or stopped, as did 27.0% of those who were categorised as having very low HbA1c levels (defined as between 6.0% and 6.4% and less than 6.0%, respectively). Of those patients who had very low levels but whose medication was not changed or stopped, less than 0.8% had raised levels at follow up.

The researchers describe their findings as a “lost opportunity to reduce overtreatment”, and say that practice guidelines and performance measures should place more focus on reducing overtreatment through deintensification.

Victoria Ruszala, specialist pharmacist in diabetes and endocrinology at North Bristol NHS Trust, who was not involved in the research, says the paper highlights the need to treat older patients in the same way as younger patients.

“This is an important point to make,” says Ruszala. “This is about being pragmatic and saying there is nothing wrong with taking away their medicines to make them safer.”

Ruszala adds that the paper is useful because it delivers hard data. “Working in secondary care we see [overtreatment] all the time and now they have come up with the figures,” she says. “What that does is give people the confidence to deintensify treatment – that that is a valid treatment choice.”

The second study[2] aimed to shed light on why overtreatment happens.

Another team of researchers, also from the University of Michigan, Ann Arbor, sent a survey to 1,222 primary care health professionals including doctors, nurse practitioners and physician assistants, of whom 594 responded.

The clinicians were presented with the hypothetical case study of a 77-year-old patient with chronic type 2 diabetes at high risk for hypoglycaemia (HbA1c level 6.5%; severe kidney disease; and receiving glipizide 10mg twice daily). They were asked a series of questions to determine whether they would consider lowering or abolishing the patient’s medication. Participants were also asked to rate the level of difficulty they would face in following the recommendation to “avoid using medications other than metformin to achieve HbA1c less than 7.5% in most older adults”.

Almost half the participants (44.9%) said they would not worry about potential harm from tight control for an older patient with an HbA1c level of 6.5% who is at high risk for hypoglycaemia. A similar proportion (42.1%) were concerned about missing performance measures if they reduced the glipizide dosage. Nearly one quarter (23.5%) were worried about future liability claims resulting from deintensification of hypoglycaemic medications.

The authors of the first study propose several reasons why a low BP or low HbA1c level had a weak association with deintensification of treatment in this group of patients: stopping a drug requires a shift in how treatment is understood by patients and explained by healthcare professionals. “It requires a transition from a simplistic focus on ‘one size fits all’ to the more nuanced balancing of risks and benefits,” they say.

Clinical uncertainty about the reliability of a single BP and HbA1c measurement and unwillingness to risk under-treatment may also influence decisions around deintensification.

“Until guidelines and performance measures specifically call for deintensification for patients who are at risk of being harmed by overtreatment, rates are likely to remain low,” the researchers conclude.

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2015.20200015

Have your say

For commenting, please login or register as a user and agree to our Community Guidelines. You will be re-directed back to this page where you will have the ability to comment.

Recommended from Pharmaceutical Press

  • Sport and Exercise Medicine for Pharmacists

    Sport and Exercise Medicine for Pharmacists

    All the information you need to provide patients with evidence-based advice on sports and exercise related health matters.

    £27.00Buy now
  • Paediatric Drug Handling

    Paediatric Drug Handling

    Written for new pharmaceutical scientists, this book provides a background in paediatric pharmacy and a comprehensive introduction to children's medication.

    £33.00Buy now
  • Drugs and the Liver

    Drugs and the Liver

    Drugs and the Liver assists practitioners in making pragmatic choices for their patients. It enables you to assess liver function and covers the principles of drug use in liver disease.

    £38.00Buy now
  • Integrated Pharmacy Case Studies

    Integrated Pharmacy Case Studies

    Over 90 case studies based on real life patient-care scenarios. Each case includes learning outcomes and references.

    £47.00Buy now
  • Non-prescription Medicines

    Non-prescription Medicines

    Reviews over-the-counter medicines, arranged by the conditions they are licensed to treat. Includes product recommendations.

    £38.00Buy now

Search an extensive range of the world’s most trusted resources

Powered by MedicinesComplete
  • Print
  • Share
  • Comment
  • Save
  • Print Friendly Version of this pagePrint Get a PDF version of this webpagePDF

Supplementary images

  • Older patients with diabetes whose blood sugar or blood pressure may be dangerously low are being overtreated because clinicians are reluctant to change their medication. In the image, a doctor speaks with an elderly female patient

Newsletter Sign-up

Want to keep up with the latest news, comment and CPD articles in pharmacy and science? Subscribe to our free alerts.