Okay, I admit it. I was predisposed to riff on and dis the headline in Medscape Medical News, “Diabetes Medications: Should You Deprescribe Them in the Elderly?” By posing a question, the headline was written, I thought, to suggest a hypothesis that tight control was neither necessary nor desirable in the elderly generally. It turns out, I am in general agreement with the author’s ideas and her specific recommendations.
When I first saw this headline I told my wife that if, when I read the piece later, the first paragraph didn’t de-sensationalize the subject, I was going to write a rant condemning it on the principal that such an idea should be advocated only on a very limited basis. Well, the first paragraph did de-sensationalize the subject.
The thrust of the article was “lowering the dose of ‘these’ drugs in patients at risk of hypoglycemia or other antihyperglycemic adverse effects, or in whom the drug’s benefit is uncertain, due to frailty, dementia, or limited life expectancy. Since the authors define “elderly” as age ≥ 65 years, I might pick a fight over the definition of “limited life expectancy,” Haven’t the authors heard that 85 is the new 65? I guess not. ;-)
It turns out Medscape was reporting on yet another deprescribing project of the Bruyère Research Institute (BRI) in Ottawa, Canada. This deprescribing idea, in general, sounds like a laudatory objective, especially since the primary antihyperglycemic target of this report was sulfonylureas (SUs), specifically Glyburide. In this, I totally agree. Glyburide pumps the pancreas dry to secrete insulin, thus lowering the patient’s blood sugar but depleting the organ’s capacity and putting the patient at high risk of hypoglycemia, which is BRI’s point.
The secondary target of the report is injected insulin, specifically an old-fashioned, “high risk” form, NPH. The BRI report suggests instead “deprescribing” NPH and substituting insulin detemir or glargine. And instead of prescribing glyburide, it suggests that doctors switch their patients to “short or long acting gliclazide.”
Where the BRI report, and Medscape, miss the mark, in my opinion, is in the overly broad statement that “many older patients with diabetes are still being treated to A1c <7%.” They explicitly accept the suggestion that people over 65 should be held to a more lax standard: <7.5% in healthy older adults and <8.5% in the very frail elderly. BRI’s purpose is to avoid “those medications that can contribute to a low blood sugar” Hypos.
Regrettably, this relaxed standard is only necessary because of the Standards of Medical Care, the failed treatment protocol dictated by the medical establishment. Such high A1c’s are totally unnecessary.
But the report provides evidence of the adverse clinical effects associated with tight glycemic control on the elderly: cardiovascular events, cognitive impairment, fractures, reduced quality of life, increased emergency room visits, and hospitalization for hypoglycemia associated with a poor prognosis. All of these are outcomes of medication regimens, and all can be mitigated by “deprescribing” in the way BRI advocates, they assert.
There is, however, another way, a way that achieves a safe and low blood sugar control without the high risk associated with SU’s like glyburide, and injected insulins like NPH, or even detemir or glargine. The article suggests various antihyperglycemic agents that have no risk of hypoglycemia, such as DPP-4s, GLP-1s agonists, and Metformin. My doctor actually laughed when I asked him if I could get a hypo from Met while fasting. ;-)There is also another way for the “elderly” to manage their blood sugar and also to completely avoid the risk of hypoglycemia: eating in a way that doesn’t raise your blood sugar: eating Very Low Carb (VLC). I was able to quickly stop all my diabetes meds (except Metformin) and lower my A1c from the mid 6s to 5.0, by eating VLC. My doctor had to immediately deprescribe my diabetes meds to “treat” several hypos in the first week! That was almost 17 years ago, and I haven’t had a hypo since, and I am now considered, clinically, non-diabetic. Now, that’s an even better outcome than switching from one antihyperglycemic med to another, no?