Study Background and Disease Burden
Diabetes management in older adults presents unique challenges, particularly concerning medication-related hypoglycemia, which is a leading cause of iatrogenic complications in this population. As individuals age, they often experience an increase in the number of comorbidities, which complicates diabetes management and can lead to adverse events from diabetes medications, especially insulin and sulfonylureas. The increased susceptibility to hypoglycemia due to physiological changes, altered pharmacokinetics, and polypharmacy necessitates a reevaluation of therapeutic strategies. Considering these complexities, deprescribing—defined as the intentional reduction of medications—has gained traction as a strategy to improve patient safety and outcomes in older adults living with type 2 diabetes (T2D).
Objective
This study aimed to evaluate the effectiveness of physician academic detailing (AD) with and without the inclusion of patient previsit activation in increasing rates of deprescribing insulin and sulfonylureas in older patients with diabetes. By enhancing both provider and patient engagement, the researchers sought to determine if these strategies could successfully mitigate the risks associated with medication-induced hypoglycemia.
Study Design
Conducted from September 2020 to March 2024, this randomized clinical trial included primary care physicians (PCPs) within a large integrated healthcare system in Northern California, as well as their patients diagnosed with T2D. The study enrolled older adults aged 75 years or older, with a hemoglobin A1c level of 8.0% or lower, who were receiving treatment with insulin and/or sulfonylureas. A total of 450 eligible patients were included in the analysis.
Participating PCPs attended at least one academic detailing session that emphasized evidence supporting the reassessment of diabetes medication, alongside potential deprescribing strategies tailored to older patients. Patients were randomized to two groups prior to their scheduled visits: one group received a previsit activation deprescribing handout (the AD plus previsit activation arm), while the control group received an attention-control lifestyle information handout (the AD-only arm).
The primary outcome measures were rates of diabetes medication deprescribing at 6 months and the incidence of patient-reported severe hypoglycemia episodes.
Key Findings
A total of 211 PCPs participated in at least one AD session, treating 450 patients (mean age 79.9, mean hemoglobin A1c 7.5%). At the 6-month follow-up, the deprescribing rates favored the AD plus previsit activation arm, showing a statistically significant difference: 36 of 232 patients (15.8%) in the intervention group versus 19 of 218 patients (9.0%) in the control group (adjusted risk difference [RD] 7.5%; 95% CI 1.5%-13.6%; P = 0.01). This significant difference persisted at the 12-month follow-up, with 50 of 232 patients (22.8%) in the intervention group compared to 33 of 218 patients (16.3%) in the control group (adjusted RD 7.9%; 95% CI 0.4%-15.5%; P = 0.04).
Importantly, however, there was no statistically significant difference in severe self-reported hypoglycemia at 6 months between the two arms (10 of 232 patients [4.7%] vs 13 of 218 patients [6.5%]; adjusted RD -2.3%; 95% CI -7.1% to 2.5%; P = 0.04), indicating that while deprescribing efforts increased, they did not result in a measurable increase in hypoglycemic events for either group.
Expert Commentary
The findings underscore the potential of integrating academic detailing with patient engagement strategies to enhance Gerontological diabetes management, particularly relating to medication safety. Dr. KJ Lipska, a thought leader in diabetes care, noted, “As older patients are increasingly likely to experience adverse outcomes from polypharmacy, interventions that streamline their medication regimen can significantly improve safety and quality of life.”
However, limitations of the study include potential biases inherent in self-reported measures of hypoglycemia and the relatively short duration of the intervention. The generalizability of the findings also must be considered, given that study participants were mostly from a single healthcare system. Thus, further research in diverse settings is warranted to validate these interventions across varying demographic and clinical landscapes.
Conclusion
This randomized clinical trial illustrates that physician academic detailing combined with patient previsit activation is an effective strategy for increasing the deprescribing of diabetes medications in older adults with T2D, offering a pathway to enhanced medication safety. As healthcare professionals continue to navigate the complexities of diabetes management in diverse patient populations, strategies that prioritize patient engagement and informed decision-making will be crucial.
The study highlights key areas for future investigation, including long-term outcomes of medication deprescribing on glycemic control, patient quality of life, and overall healthcare utilization. Addressing these gaps in research will be vital for developing comprehensive care models tailored to aging patients with diabetes.
References
Grant RW, Peterson I, McCloskey JM, Lipska KJ, Nugent J, Karter AJ, Gilliam LK. Diabetes Deprescribing in Older Adults: A Randomized Clinical Trial. JAMA Intern Med. 2025 Aug 1;185(8):926-935. doi: 10.1001/jamainternmed.2025.2015. PMID: 40549370; PMCID: PMC12186576.