Most Older Diabetics Don't Get Recommended Medication Tweaks

 

• Guidelines recommend individualizing HbA1c goals to health status in older adults with type 2 diabetes.
• A review of electronic health records found that most older adults with type 2 diabetes outside target HbA1c goals didn't receive medication adjustments in the right direction.
• Only 17% of below-goal patients had their regimen deintensified, while 33% of above-goal patients had their treatment intensified.

Most older adults with type 2 diabetes whose HbA1c level was outside the American Diabetes Association (ADA)-recommended target did not have their medications adjusted, a review of electronic health records indicated.

Among nearly 90,000 patients ages 65 and older, only 16.9% of those with an HbA1c below guideline goals had their regimen deintensified. Meanwhile, only 32.8% of patients whose HbA1c was above goal had their treatment intensified, reported researchers led by Phuc Le, PhD, MPH, of the Cleveland Clinic, in JAMA Internal Medicine.

"There are opportunities to improve treatment alignment at both ends of the glycemic spectrum," with the goal of achieving the right treatment intensity for each individual patient, Le told MedPage Today.

"Some patients in poor health with HbA1c substantially below goal who may be most vulnerable to the harms of overly intensive glycemic control continued to have treatment intensified," she said. "At the same time, some patients in good health with HbA1c above goal who could benefit from intensive control did not receive treatment intensification."

ADA guidelines recommend individualizing HbA1c goals based on health status. Patients with significant cognitive or functional limitations, frailty, or severe comorbidities should follow less stringent targets to avoid hypoglycemia. In contrast, healthier patients with longer life expectancies may follow a more intensive regimen with goals similar to younger adults.

"Clinicians should consider the patient's overall health, comorbidities, functional status, life expectancy, and treatment preferences when setting a glycemic goal, and then periodically reassess whether the medication regimen remains appropriate for that goal," Le advised.

For the analysis, researchers evaluated electronic health record data from 2019 through 2023. HbA1c was defined as "at goal" if it was between 0 and 1.5 percentage points below the ADA's specified targets, stratified by health status as follows:

• Poor health (one or more terminal conditions): Below 9%
• Intermediate health (three or more chronic conditions): Below 8%
• Good health (neither condition): Below 7.5%

Outside of the at-goal range, HbA1c levels were categorized as either below or above goal. Intensification and deintensification were defined as an increase or decrease in the number of diabetes drug classes or non-insulin drug dosages within 3 months after versus 3 months before the index HbA1c ​measurement.

Across the study period, 7.9% of patients had good health, 61.6% had intermediate health, and 30.6% had poor health status. Overall, 13.8% of patients had above-goal, 37.8% had at-goal, and 48.4% had below-goal HbA1c​ levels. Average age of the cohort was roughly 71.6 years, and half of the patients were men.

In 2023, those with above-goal HbA1c ​were more likely to experience medication intensification (32.8% vs 16.1%, P<0.001) or deintensification (20.3% vs 16.3%, P<0.001) compared with at-goal patients. Intensification patterns were similar across health statuses, including among healthy older adults.

"This represents a missed opportunity to improve glycemic control in otherwise healthy older adults, placing them at risk for long-term complications, such as retinopathy, nephropathy, and cardiovascular disease," the authors wrote.

Conversely, those with below-goal HbA1c ​had a similar rate of deintensification compared with at-goal patients (16.9% vs 16.3%, P=0.338) and a lower rate of intensification (7.7% vs 16.1%, P<0.001) compared with at-goal patients.

However, intensification for below-goal levels occurred most frequently in patients with poor health. The researchers called this finding concerning, "because intensive glycemic control in frail or medically complex older adults is associated with increased risks of hypoglycemia and other adverse outcomes."

Deintensification should not be viewed as providing less care, Le stressed.

"In some older adults, safely reducing medication burden can be an important part of good diabetes care," she noted. "The goal is to balance the long-term benefits of glycemic control against treatment burden and potential adverse effects, particularly hypoglycemia, in patients with substantial comorbidity or limited life expectancy."

The study could not determine why individual clinicians intensified, deintensified, or maintained treatment, Le acknowledged.

"Therefore, these results should not be interpreted to mean that every HbA1c value outside the guideline range requires a medication change," she said. "Rather, they highlight opportunities for clinicians to make individualized glycemic goals a more explicit part of clinical decision-making."

Next steps should focus on improving adherence to guideline recommendations and leveraging safer medication options, the authors concluded.

Disclosures

Le reported no disclosures. Co-authors reported relationships with the NIH, the Patient-Centered Outcomes Research Institute, Bayer, and Blue Cross Blue Shield Association.

Primary Source

JAMA Internal Medicine

Source Reference: Le P, et al "Intensification and deintensification of diabetes medications among older adults with type 2 diabetes" JAMA Intern Med 2026; DOI: 10.1001/jamainternmed.2026.3483.

https://www.medpagetoday.com/endocrinology/diabetes/122555