Optimization of type 2 diabetes care in adults aged 65 or older: Practical approach to deintensification

The benefits of lowering blood glucose levels are limited and potentially burdensome and even dangerous in people with limited life expectancies. Diabetes management in those over 65, in particular, should be individualized. James W. Mold, MD, MPH

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Effective diabetes management, particularly in older and frail adults, requires a nuanced approach that balances the benefits of antihyperglycemic medications with the risks of intensive glycemic control. While certain diabetes medications are important to the prevention of chronic complications of diabetes, intensive glycemic management can increase the risk of hypoglycemia, potentially leading to serious adverse outcomes (eg, falls, seizures, hospitalizations, death). In patients aged 65 or older and those with frailty, a tailored approach to diabetes care is crucial. A patient-centred approach might include individualizing glycemic targets and reducing the intensity of both pharmacologic treatment and routine monitoring to prioritize patient safety and quality of life. Implementing such patient-centred care requires clinicians to thoroughly consider each patient’s overall health, preferences, and social context, thus ensuring that treatment decisions align with the patient’s personal goals of care and life circumstances.

Author/s:

Julia B Bardoczi, Carole E Aubert

Glucose Self-monitoring in Non–Insulin-Treated Patients With Type 2 Diabetes in Primary Care Settings

Jeffrey Wilson — Tue, 11 Dec 2018 21:11:53 +0000

Date Added:

December 11, 2018

Journal/Publication:

JAMA Internal Medicine

Publisher:

American Medical Association

Publication Date:

July 10, 2017

Issue:

Volume:

177

Pages:

920-929

URL:

Glucose Self-monitoring in Non–Insulin-Treated Patients With Type 2 Diabetes in Primary Care Settings

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamainternmed.2017.1233

Keywords

type 2 diabetes

blood glucose

quality of life

PMID (1):

28600913

MeSH

blood glucose

diabetes mellitus, type 2

quality of life

insulin

In patients with type 2 diabetes, daily finger stick blood glucose measurement had no effect on Hgb A1c levels or health-related quality of life.

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IMPORTANCE:

The value of self-monitoring of blood glucose (SMBG) levels in patients with non-insulin-treated type 2 diabetes has been debated.

OBJECTIVE:

To compare 3 approaches of SMBG for effects on hemoglobin A1c levels and health-related quality of life (HRQOL) among people with non-insulin-treated type 2 diabetes in primary care practice.

DESIGN, SETTING, AND PARTICIPANTS:

The Monitor Trial study was a pragmatic, open-label randomized trial conducted in 15 primary care practices in central North Carolina. Participants were randomized between January 2014 and July 2015. Eligible patients with type 2 non-insulin-treated diabetes were: older than 30 years, established with a primary care physician at a participating practice, had glycemic control (hemoglobin A1c) levels higher than 6.5% but lower than 9.5% within the 6 months preceding screening, as obtained from the electronic medical record, and willing to comply with the results of random assignment into a study group. Of the 1032 assessed for eligibility, 450 were randomized.

INTERVENTIONS:

No SMBG, once-daily SMBG, and once-daily SMBG with enhanced patient feedback including automatic tailored messages delivered via the meter.

MAIN OUTCOMES AND MEASURES:

Coprimary outcomes included hemoglobin A1c levels and HRQOL at 52 weeks.

RESULTS:

A total of 450 patients were randomized and 418 (92.9%) completed the final visit. There were no significant differences in hemoglobin A1c levels across all 3 groups (P = .74; estimated adjusted mean hemoglobin A1c difference, SMBG with messaging vs no SMBG, -0.09%; 95% CI, -0.31% to 0.14%; SMBG vs no SMBG, -0.05%; 95% CI, -0.27% to 0.17%). There were also no significant differences found in HRQOL. There were no notable differences in key adverse events including hypoglycemia frequency, health care utilization, or insulin initiation.

CONCLUSIONS AND RELEVANCE:

In patients with non-insulin-treated type 2 diabetes, we observed no clinically or statistically significant differences at 1 year in glycemic control or HRQOL between patients who performed SMBG compared with those who did not perform SMBG. The addition of this type of tailored feedback provided through messaging via a meter did not provide any advantage in glycemic control.

Author/s:

Young, Laura A., Buse, John B., Weaver, Mark A., Vu, Maihan B., Mitchell, C. Madeline, Blakeney, Tamara, Grimm, Kimberlea, Rees, Jennifer, Niblock, Franklin, Donahue, Katrina E.