Are Seniors With Diabetes Overtreated?

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Many older people with diabetes may be exposed to potential harm because doctors are trying to keep overly tight control of their blood sugar levels, a new study argues.

Researchers found that nearly two-thirds of older diabetics who are in poor health have been placed on a diabetes management regimen that strictly controls their blood sugar, aiming at a targeted hemoglobin A1C level of less than 7 percent.

But these patients are achieving that goal through the use of medications that place them at greater risk of hypoglycemia, a reaction to overly low blood sugar that can cause abnormal heart rhythms, and dizziness or loss of consciousness, the researchers said.

Further, tight diabetes control did not appear to benefit the patients, the researchers report Jan. 12 in JAMA Internal Medicine. The percentage of seniors with diabetes in poor health did not change in more than a decade, even though many had undergone years of aggressive blood sugar treatment.

“There is increasing evidence that tight blood sugar control can cause harm in older people, and older people are more susceptible to hypoglycemia,” said lead author Dr. Kasia Lipska, an assistant professor of endocrinology at Yale University School of Medicine. “More than half of these patients were being treated with medications that are unlikely to benefit them and can cause problems.”

Diabetes is common among people 65 and older. But doctors have struggled to come up with the best way to manage diabetes in seniors alongside the other health problems they typically have, researchers said in background information with the study.

For younger and healthier adults, the American Diabetes Association has recommended therapy that aims at a hemoglobin A1C level of lower than 7 percent, while the American Association of Clinical Endocrinologists recommends a target of lower than 6.5 percent, the authors noted. The A1C test provides a picture of your average blood sugar levels for the past two to three months.

By tightly controlling blood sugar levels, doctors hope to stave off the complications of diabetes, including organ damage, blindness, and amputations due to nerve damage in the limbs.

In this study, the authors analyzed 2001-2010 data on 1,288 diabetes patients 65 and older from a U.S. survey.

The patients were divided into three groups based on their health status: About half were considered relatively healthy despite their diabetes; 28 percent had complex/intermediate health, in that they also suffered from three or more other chronic conditions or had difficulty performing some basic daily activities. Roughly 21 percent had very complex/poor health, and were either dependent on dialysis or struggling with activities of daily living.

Overall, 61.5 percent of all these patients had achieved tight blood glucose control. And a little more than half of them had done so by relying on drugs that can dramatically lower blood sugar levels. These include insulin and sulfonylureas, a medication that prompts the pancreas to produce more insulin.

People with diabetes either don’t produce insulin, a hormone needed to convert food into energy, or cells don’t process it properly.

Despite this aggressive treatment, the proportions of older diabetics in good and poor health did not significantly change during the 10-year study period, calling into question whether doctors are overtreating these patients to no real benefit, Lipska said.

“I don’t think we should be using insulin or sulfonylureas in older patients,” she said. “This study shows that with people in poorer health, we’re treating them aggressively with these drugs, and it makes no difference.”

Dr. Alan Garber, of the Baylor College of Medicine in Houston, said the study does call into question the use of insulin or sulfonylureas to treat diabetes in older adults, but does not necessarily invalidate the goal of tight blood sugar control.

“I find it very interesting that the study shows that certain medications produce adverse outcomes, but concludes that the goal of treatment is the problem and not the medication,” said Garber, a professor of diabetes, endocrinology and metabolism. “An equally valid conclusion is that it shows that many of the newer medications, which have been proven in multiple trials to have superior outcomes with regards to hypoglycemia, should have been used in patients at risk for hypoglycemia.”

However, both Garber and Lipska agreed that for older patients with diabetes, a “one-size-fits-all” diabetes treatment plan will not work.

“We need to individualize diabetes management, including the goals,” Garber said. “For some individuals, the traditional goals are perhaps too low for their ability to tolerate it. On the other hand, you have to try them on medications with a low risk of hypoglycemia.”

Lipska said she would “encourage people to talk with their physicians and to try to understand better what are the potential benefits and what are the risks of treatment. There isn’t one universal goal for everyone.”

More information

For more on seniors and diabetes, visit the American Diabetes Association.

Source: HealthDay

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