Abstract
Objectives
The benefit of alerting clinical staff to low plasma glycated hemoglobin (HbA1c) in
patients aged 75 years and older who receive antidiabetic drugs remains uncertain.
Design, Setting, and Participants
In a randomized controlled trial, 1684 patients with HbA1c ≤ 6.5% who received antidiabetic
drugs were assigned to have an e-mail alert sent to their physician, and 1643 were
assigned to have no such alert (control group). The primary outcome of the trial was
annual death. Secondary outcomes included antidiabetic drug dose reduction and HbA1c
change.
Results
In the first quarter, antidiabetic drug-defined daily doses were reduced on average
by 10.4 ± 35.8 (16% ± 55%) in the intervention group and by 6.4 ± 36.1 (10% ± 56%)
in the control group (difference −4.1 ± 1.2, 95% confidence interval [CI] −6.5 to −1.6;
P = .001). Measured HbA1c levels were raised by a mean (± standard deviation) of 0.28 ± 0.77
in the intervention group and by 0.18 ± 0.57 in the control group (difference 0.10 ± 0.02,
95% CI –0.15 to −0.059, P < .001). One year after the alerts, 121 patients (7.2%) died in the intervention
group and 107 patients (6.5%) died in the control group (relative risk 1.1, 95% CI
0.86-1.42; P = .44).
Conclusions and Implications
In this trial, alerting clinical staff to low HbA1c in patients aged 75 years and
older treated with antidiabetic medicines was associated with mildly reduced antidiabetic
doses and increased HbA1c but was not associated with a significant difference in
survival rate compared with usual clinical care.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of the American Medical Directors AssociationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Hypoglycemia in older people—A less well recognized risk factor for frailty.Aging Dis. 2015; 6: 156-167
- Treating the elderly diabetic patient: Special considerations.Diabetes Metab Syndr Obes. 2014; 7: 391-400
- Impact of glycemic control on daily living activities over 1-year follow-up in memory clinic patients with diabetes.J Am Med Dir Assoc. 2019; 20: 792-794
- Reappraisal of metformin efficacy in the treatment of type 2 diabetes: A meta-analysis of randomised controlled trials.PLoS Med. 2012; 9: e1001204
- Impact of metformin on cardiovascular disease: A meta-analysis of randomised trials among people with type 2 diabetes.Diabetologia. 2017; 60: 1620-1629
- Survival as a function of HbA(1c) in people with type 2 diabetes: A retrospective cohort study.Lancet. 2010; 375: 481-489
- Effect of intensive treatment of hyperglycaemia on microvascular outcomes in type 2 diabetes: An analysis of the ACCORD randomised trial.Lancet. 2010; 376: 419-430
- Potential overtreatment of diabetes mellitus in older adults with tight glycemic control.JAMA Intern Med. 2015; 175: 356-362
- Deprescribing antihyperglycemic agents in older persons: Evidence-based clinical practice guideline.Can Fam Physician. 2017; 63: 832-843
- Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: Addressing polypharmacy.Arch Intern Med. 2010; 170: 1648-1654
- Deprescribing medications for chronic diseases management in primary care settings: A systematic review of randomized controlled trials.J Am Med Dir Assoc. 2018; 19: 923-935.e2
- The effectiveness of implementing an electronic health record on diabetes care and outcomes.Health Serv Res. 2012; 47: 1522-1540
- Employing the electronic health record to improve diabetes care: A multifaceted intervention in an integrated delivery system.J Gen Intern Med. 2008; 23: 379-382
- The Utah Remote Monitoring Project: Improving health care one patient at a time.Diabetes Technol Ther. 2014; 16: 653-660
- The Low Indexes of Metabolism Intervention Trial (LIMIT): Design and baseline data of a randomized controlled clinical trial to evaluate how alerting primary care teams to low metabolic values, could affect the health of patients aged 75 or older.BMC Health Serv Res. 2018; 18: 4
- Which factors affect the implementation of geriatric recommendations by primary care physicians?.Isr J Health Policy Res. 2017; 6: 7
- In pursuit of normoglycaemia: The overtreatment of type 2 diabetes in general practice.Br J Gen Pract. 2015; 65: 334-335
- HbA1c overtesting and overtreatment among US adults with controlled type 2 diabetes, 2001-13: Observational population based study.BMJ. 2015; 351: h6138
Article info
Publication history
Published online: October 03, 2019
Footnotes
This work was supported by Dangoor Personalized Medicine Fund at Bar-Ilan University. The Dangoor fund was not involved in the design, methods, subject recruitment, data collections, analysis and preparation of the paper.
The authors declare no conflicts of interest.
Identification
Copyright
© 2019 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
