Realigning diabetes regimens in older adults: a 4S Pathway to guide simplification and deprescribing strategies

Abstract

Treating older people with diabetes is challenging due to multiple medical comorbidities that might interfere with patients' ability to perform self-care. Most diabetes guidelines focus on improving glycaemia through addition of medications, but few address strategies to reduce medication burden for older adults-a concept known as deprescribing. Strategies for deprescribing might include stopping high-risk medications, decreasing the dose, or substituting for less harmful agents. Accordingly, glycaemic management strategies for older adults with type 1 and type 2 diabetes not responding to their current regimen require an understanding of how and when to realign therapy to meet patient's current needs, which represents a major clinical practice gap. With the gap in guidance on how to deprescribe or otherwise adjust therapy in older adults with diabetes in mind, the International Geriatric Diabetes Society, an organisation dedicated to improving care of older individuals with diabetes, convened a Deprescribing Consensus Initiative in May, 2023, to discuss Optimization of diabetes treatment regimens in older adults: the role of de-prescribing, de-intensification and simplification of regimens. The recommendations from this group initiative are discussed and described in this Review.

Figure 1:

The 4S Pathway

Figure 2:. 4S Pathway step 1—seeking triggers

Selected examples of triggers that should prompt further investigation into diabetes-related contributions to declining health or wellbeing. CGM=continuous glucose monitoring.

Figure 3:. Stepwise approach to lowering risk of hypoglycaemia based on CGM

CGM=continuous glucose monitoring. NPH=neutral protamine Hagedorn.

Figure 4:. 4S Pathway step 4 for type 2 diabetes

CGM=continuous glucose monitor. DPP-4=dipeptidyl peptidase-4. eGFR=estimated glomerular filtration rate. GIP=glucose-dependent insulinotropic polypeptide; GLP-1=glucagon-like peptide 1. NPH=neutral protamine Hagedorn. SGLT2=sodium-glucose co-transporter-2. *Basal insulin analogues preferred over NPH due to lower risk of hypoglycaemia. †Fasting glucose goal: 90–150 mg/dL, measured over 1 week with fingerstick blood glucose monitor or CGM. ‡Might be prescribed for chronic kidney disease or heart failure independent of type 2 diabetes or eGFR; monitor for adverse events. §Evaluate for gastrointestinal adverse events as possible cause of weight loss. ¶Includes dual GIP and GLP-1 receptor agonists. ||Monitor for oedema and other adverse events. **Selection based on person-specific considerations (table 3).

Figure 5:. 4S Pathway step 4 for type 1 diabetes

BGM=blood glucose monitoring. CGM=continuous glucose monitor. CV%=coefficient of variation. *Any recurrent hypoglycaemia is detrimental, including level 1 (≤70 mg/dL), level 2 (<54 mg/dL), or level 3 (requiring help from another person).