Scaling Back Diabetes Treatment

Here at DiabetesSelfManagement.com, and in almost every other source of health information, much of the emphasis in diabetes management is placed on lowering your blood glucose level. And for good reason — according to a 2013 study in the journal Diabetes Care, only 52.5% of U.S. adults with diabetes were found to have an HbA1c level (a measure of long-term blood glucose control) below 7%. (The American Diabetes Association recommends that most adults with diabetes aim for an HbA1c below 7%, and that some try for an even lower target.) In addition, the 2013 study found that only 51.1% reached a blood pressure level below 130/80 mm Hg, a target recommended for many people with diabetes.

Given these numbers, it may seem strange to worry about lowering blood glucose or blood pressure by too much. But in any individual patient, a doctor should be able evaluate whether a treatment for either condition is effective or should be scaled back. According to a recent study, though, in most older adults with diabetes who have low or very low blood pressure or HbA1c, this just isn’t happening.

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The study, published late last month in the journal JAMA Internal Medicine, used data from the Veterans Health Administration to look at over 200,000 older adults (age 70 or above) with diabetes. All of the study participants were being treated for either high blood pressure or high blood glucose, or both, with drugs other than (or in addition to) ACE inhibitors and metformin. The researchers excluded these drugs from their criteria because ACE inhibitors are often used to treat conditions other than high blood pressure, and because metformin doesn’t generally carry the risk of hypoglycemia (low blood glucose) that other diabetes drugs — including insulin — carry.

The aim of the study was to find out how often participants with low blood pressure, or a low HbA1c level, had their treatments “deintensified,” or scaled back. To do this, the researchers looked at these measurements in participants, and also at their prescriptions to see if any treatments were changed within six months of getting a low blood pressure or HbA1c reading. (Very low blood pressure was defined as below 120/65, and moderately low as 120/65 to 129/65. Very low HbA1c was defined as below 6%, and moderately low as 6.0% to 6.4%.)

The researchers found that in participants who didn’t have low blood pressure, 15.1% saw a scaling back of their treatment. (This could have been done for many reasons, and served as a baseline.) In participants with moderately low blood pressure, 16.0% saw their treatment deintensified, as did 18.8% of those with very low blood pressure — barely any different from the numbers seen in people without low blood pressure. For HbA1c, the differences were slightly more pronounced: In participants without a low HbA1c level, 17.5% saw their treatment scaled back. In those with moderately low HbA1c, 20.9% experienced deintensification, as did 27.0% of those with very low HbA1c.

As an article on the deintensification study at 2 Minute Medicine notes, it’s possible that some participants had their insulin regimens scaled back in ways that weren’t captured by the study. Still, it’s clear that most people with low blood pressure or HbA1c levels aren’t seeing their treatments scaled back, and these people may be at higher risk for dangerously low blood pressure or blood glucose levels. According to the American Heart Association, very low blood pressure can cause dizziness, fainting, blurred vision, fatigue, and nausea, among other symptoms. Symptoms of very low blood glucose may include weakness, confusion, hunger, dizziness, trembling, and sweating — and, in severe cases, coma and even death.

What’s your take on this study — are you surprised that more people with diabetes don’t see their blood pressure and blood glucose treatments scaled back? Do you suspect that this is true among the wider diabetes population, and not just in the Veterans Health Administration? Have you ever experienced low blood glucose, or blood pressure, that you think might have been related to overtreatment? If you’ve reached your blood pressure or HbA1c goals, has your doctor ever brought up the idea of scaling back your treatments? Why do you think doctors seem resistant to scaling back treatments in patients who are good candidates for it? Leave a comment below!