TY - JOUR
T1 - A Qualitative Study of Perspectives of Older Adults on Deintensifying Diabetes Medications
AU - Pilla, Scott J.
AU - Meza, Kayla A.
AU - Schoenborn, Nancy L.
AU - Boyd, Cynthia M.
AU - Maruthur, Nisa M.
AU - Chander, Geetanjali
N1 - Funding Information:
Dr. Pilla was supported by the Johns Hopkins KL2 Clinical Research Scholars Program (KL2TR003099) and the National Institute of Diabetes and Digestive and Kidney Diseases (K23DK128572). Dr. Schoenborn was supported by the National Institute on Aging (K76AG059984). Dr. Boyd was supported by the U.S. Deprescribing Research Network (R24AG064025) and by K24AG056578, both from the National Institute on Aging. Dr. Chander was funded by the National Institute on Alcohol Abuse and Alcoholism (K24AA027483). The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Publisher Copyright:
© 2022, The Author(s), under exclusive licence to Society of General Internal Medicine.
PY - 2023/3
Y1 - 2023/3
N2 - Background: While many older adults with type 2 diabetes have tight glycemic control beyond guideline-recommended targets, deintensifying (stopping or dose-reducing) diabetes medications rarely occurs. Objective: To explore the perspectives of older adults with type 2 diabetes around deintensifying diabetes medications. Design: This qualitative study used individual semi-structured interviews, which included three clinical scenarios where deintensification may be indicated. Participants: Twenty-four adults aged ≥65 years with medication-treated type 2 diabetes and hemoglobin A1c <7.5% were included (to thematic saturation) using a maximal variation sampling strategy for diabetes treatment and physician specialty. Approach: Interviews were independently coded by two investigators and analyzed using a grounded theory approach. We identified major themes and subthemes and coded responses to the clinical scenarios as positive (in favor of deintensification), negative, or ambiguous. Key Results: Participants’ mean age was 74 years, half were women, and 58% used a sulfonylurea or insulin. The first of four major themes was fear of losing control of diabetes, which participants weighed against the benefits of taking less medication (Theme 2). Few participants viewed glycemic control below target as a reason for deintensification and a majority would restart the medication if their home glucose increased. Some participants were anchored to their current diabetes treatment (Theme 3) driven by unrealistic views of medication benefits. A trusting patient-provider relationship (Theme 4) was a positive influence. In clinical scenarios, 8%, 4%, and 75% of participants viewed deintensification positively in the setting of poor health, limited life expectancy, and high hypoglycemia risk, respectively. Conclusions: Optimizing deintensification requires patient education that describes both individualized glycemic targets and how they will change over the lifespan. Deintensification is an opportunity for shared decision-making, but providers must understand patients’ beliefs about their medications and address misconceptions. Hypoglycemia prevention may be a helpful framing for discussing deintensification.
AB - Background: While many older adults with type 2 diabetes have tight glycemic control beyond guideline-recommended targets, deintensifying (stopping or dose-reducing) diabetes medications rarely occurs. Objective: To explore the perspectives of older adults with type 2 diabetes around deintensifying diabetes medications. Design: This qualitative study used individual semi-structured interviews, which included three clinical scenarios where deintensification may be indicated. Participants: Twenty-four adults aged ≥65 years with medication-treated type 2 diabetes and hemoglobin A1c <7.5% were included (to thematic saturation) using a maximal variation sampling strategy for diabetes treatment and physician specialty. Approach: Interviews were independently coded by two investigators and analyzed using a grounded theory approach. We identified major themes and subthemes and coded responses to the clinical scenarios as positive (in favor of deintensification), negative, or ambiguous. Key Results: Participants’ mean age was 74 years, half were women, and 58% used a sulfonylurea or insulin. The first of four major themes was fear of losing control of diabetes, which participants weighed against the benefits of taking less medication (Theme 2). Few participants viewed glycemic control below target as a reason for deintensification and a majority would restart the medication if their home glucose increased. Some participants were anchored to their current diabetes treatment (Theme 3) driven by unrealistic views of medication benefits. A trusting patient-provider relationship (Theme 4) was a positive influence. In clinical scenarios, 8%, 4%, and 75% of participants viewed deintensification positively in the setting of poor health, limited life expectancy, and high hypoglycemia risk, respectively. Conclusions: Optimizing deintensification requires patient education that describes both individualized glycemic targets and how they will change over the lifespan. Deintensification is an opportunity for shared decision-making, but providers must understand patients’ beliefs about their medications and address misconceptions. Hypoglycemia prevention may be a helpful framing for discussing deintensification.
KW - adverse reactions
KW - aging
KW - deprescriptions
KW - diabetes mellitus, type 2
KW - drug-related side effects
KW - hypoglycemia
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U2 - 10.1007/s11606-022-07828-3
DO - 10.1007/s11606-022-07828-3
M3 - Article
C2 - 36175758
AN - SCOPUS:85139230275
SN - 0884-8734
VL - 38
SP - 1008
EP - 1015
JO - Journal of general internal medicine
JF - Journal of general internal medicine
IS - 4
ER -