1. Based on Veterans Affairs primary care data on older adults with longstanding diabetes, deintensification of hypertension therapy, not including angiotensin converting enzyme inhibitors (ACE-I) amongst patients with moderately low and very low blood pressures (BP) occurred less than 20% of the time.
2. Similarly, deintensification of diabetes therapy, not including metformin, amongst the same population with moderately low (HgbA1c 6-6.4%) and very low (HgbA1c <6%) blood sugars occurred less than 20% of the time.
Evidence Rating Level: 2 (Good)
Study Rundown: Treatment guidelines about tight control of diabetes and blood pressure in the appropriate clinical settings have significantly reduced the undertreatment of these conditions. However, overtreatment is the harm that can come from this. Based on the important study, Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, tight control of blood sugars and blood pressures in patients with longstanding diabetes leads to adverse outcomes, especially in older adults. Newer guidelines do reflect this, but the deintensification of therapy is not always done. This study, which evaluated data from Veterans Affairs primary care, was conducted to determine whether deintensification of blood pressure and tight diabetes control occurred in older adults with longstanding diabetes. The results of the study showed that in patients with moderately low (BP 120-129/65 mmHg) and very low (BP <120/65) blood pressures, fewer than 20% of them underwent deintensification of therapy. Similarly, the study showed that in patients with moderately low (HgbA1c 6-6.4%) and very low (HgbA1c <6%) blood sugars, fewer than 30% of them underwent deintensification of therapy.
The strength of the study was the size of the cohort evaluated, and maintaining definitions of categories of blood pressure and blood sugar similar to the ACCORD trial, from which the guidelines are based. The weaknesses were inability to capture changes in insulin regimen (only whether it was discontinued) in pharmacy records and the inability to capture changes in medications patients filled from outside pharmacies.
Click to read the study, published today in JAMA Internal Medicine
Relevant Reading: Potential overtreatment of diabetes mellitus in older adults with tight glycemic control.
In-Depth [retrospective cohort]: This retrospective cohort study was based on data from the primary care setting of Veterans Affairs hospitals in the calendar year 2012. Two cohorts were made, one for blood pressure and the other for diabetes control, both consisting of patients with known diabetes and age greater than 70 years. Low dose ACE-I was not counted as an antihypertensive since it has other indications in this cohort, and metformin was not counted as continued diabetic treatment since it does not cause hypoglycemia. Patients with heart failure and cirrhosis were excluded. Blood pressures were defined as follows: very low (<120/65), moderately low (120-129/65), not low (>130/65), and high (>140/90). Diabetes, based on HgbA1c measurements, was defined as follows: very low (<6%), moderately low (6-6.4%), not low (≥6.5%), and high (>7.5%). The primary outcome was the percentage of patients in two aforementioned cohorts who underwent deintensification of therapy.
In the blood pressure cohort, 25 955 of 211 667 patients (12.4%) received treatment to achieve a moderate low blood pressure, and 81 226 patients (38.4%) developed a very low BP while on treatment. Chance of deintensification in patients with moderate low BP (16.0%) and very low BP (18.8%) was slightly higher compared to those with not low BP (15.1%). In the diabetes control cohort, 23 769 of 179 991 (13.2%) received treatment to achieve a moderately low HgbA1c, and 12 917 (7.2%) received treatment resulting in a very low HgbA1c. Chance of deintensification of therapy in the moderately low (20.9%) and very low (27.0%) categories was somewhat higher than in the not low (17.5%) category.
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