Okay, I admit it. I was predisposed to riff on and dis this story 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 would strongly disagree 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 depletes the pancreas’ insulin supply, thus, while lowering the patient’s blood glucose, also depletes the organ’s capacity to continue to make insulin and puts 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” – in other words, hypos.
Regrettably, this relaxed standard is only necessary because of the failed treatment protocol dictated by the failed dietary paradigm prescribed by government and the entire medical establishment. Such high A1c’s are totally unnecessary. Type 2 diabetes is a dietary disease.
But the report does provide evidence of the adverse clinical effects associated with tight glycemic control (with medications) 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 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 practicing extended fasting. ;-)
There is also another way for the “elderly” to manage their blood sugar and also to completely avoid the risk of hypoglycemia: to eat in a way that doesn’t raise your blood sugar. That way: eat 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 18 years ago, and I haven’t had a hypo since, and I am now considered, clinically, non-diabetic. Now, I think you’d agree that that’s an even better outcome than switching from one antihyperglycemic med to another.