De-Intensification Of Blood Glucose Lowering Medication In People Identified As Being Over-Treated: A Mixed Methods Study

Figures & data

Figure 1 Algorithm to set the HbA1c target (Dutch diabetes guideline). This algorithm shows that patients aged <70 years and those aged ≥70 years treated with a lifestyle advice only or with metformin monotherapy should achieve an HbA1c target ≤ 7% (53 mmol/mol). Patients above 70 years who are using more blood glucose-lowering agents than metformin only and with a diabetes duration less than 10 years should achieve an HbA1c ≤ 7.5% (58 mmol/mol), those with a diabetes duration above 10 years have a target ≤ 8% (64 mmol/mol).

Table 1 Baseline Characteristics

	No De-Intensification Of Treatment (n=28)	De-Intensification Of Treatment (n=36)	p-value
	N (%)	N (%)
Age (years)^a	75.0 (72.0–82.8)	76.5 (72.3–82.0)	0.7
Sex (male)	19 (67.9)	18 (50.0)	0.15
Diabetes duration (years)^a	12.5 (6.3–18.0)	12.0 (8.3–16.8)	0.95
HbA1c at start of index period (mmol/mol)^a	48.5 (44.0–50.8)	47.0 (45.0–50.0)	0.84
Target HbA1c < 58 mmol/mol	11 (39.3)	12 (33.3)	0.62
Target HbA1c < 64 mmol/mol	17 (60.7)	24 (66.7)	0.62
Macrovascular complications	8 (28.6)	9 (25.0)	0.75
Microvascular complications^b	10 (52.6)	13 (52.0)	0.97
Comorbidity	7 (25.0)	20 (55.6)	0.01
Deceased	3 (10.7)	2 (5.6)	0.65
Polypharmacy^c	14 (50.0)	24 (66.7)	0.18
Living alone	9 (32.1)	10 (27.8)	0.71
Frailty index > 0.2	16 (57.1)	23 (63.9)	0.58
Sulphonylureas	14 (50.0)	27 (75.0)	0.04
Insulin monotherapy	1 (3.6)	2 (5.6)	1
Oral therapy + insulin	5 (17.9)	6 (16.7)	0.9

Notes: ^aMedian (interquartile range); ^bTwenty missing cases (missing data regarding microvascular complications in index period); ^cUse of five or more medications.

Table 2 Results, Adjustments And Possible Adverse Events Of Diabetes Treatment

	No De-Intensification Of Treatment (n=28)	De-Intensification Of Treatment (n=36)	p-Value
	N (%)	N (%)
HbA1c at end of index period (mmol/mol)^a	54.5 (47.5–57.8)	51.0 (48.0–55.0)	0.12
Difference in HbA1c^a, b	6.5 (3.3–9.5)	3.0 (−1.0–7.0)	0.05
Over-treated^c	9 (37.5)	25 (71.4)	0.01
On target^c	12 (50.0)	8 (22.9)	0.03
Undertreated^c	3 (12.5)	2 (5.7)	0.36
Lowering of:
- Sulphonylureas^d	–	23 (85.2)	–
- Insulin^d	–	7 (87.5)	–
- Other glucose lowering medication^d	–	6 (22.2)	–
Intensification of treatment	10 (35.7)	13 (36.1)	0.97
Hypoglycaemia	5 (17.9)	9 (25.0)	0.49
Fall incidents	6 (21.4)	8 (22.2)	0.94
Out-of-hours general practitioners service visit	5 (17.9)	5 (13.9)	0.66
Emergency room visit	5 (17.9)	10 (27.8)	0.35
HONK/DKA^e	0 (0)	0 (0)	–

Notes: ^aMedian (interquartile range); ^bDifference in HbA1c (end of index period – start of index period); ^cFive missing cases; ^d% of total patients in the de-intensification group using this type of medication; ^eHyperosmolar non-ketotic coma/diabetic ketoacidosis.

Table 3 Characteristics Of Patients, Participating In Focus Groups

Patient Characteristics	N (%)	Median (Interquartile Range)
Sex
Male	4 (57.1)
Age (years)		77.0 (75.0–84.0)
Ethnicity
Western-European	5 (71.4)
Moroccan	1 (14.3)
Not specified	1 (14.3)
Diabetes duration (years)		13.0 (6.0–27.0)
Living alone	1 (14.3)
HbA1c target
58 mmol/mol	2 (28.6)
64 mmol/mol	5 (71.4)
HbA1c value (mmol/mol)		48.0 (44.0–51.0)
De-intensification of therapy	4 (57.1)
Frailty index > 0.2	4 (57.1)
Hypoglycaemia	2 (28.6)
Fall incidents	1 (14.3)
Out-of-hours general practice service visit	0 (0)
Emergency room visit	2 (28.6)