Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.
J Gen Intern Med. 2023 Mar;38(4):1008-1015. doi: 10.1007/s11606-022-07828-3. Epub 2022 Sep 29.
While many older adults with type 2 diabetes have tight glycemic control beyond guideline-recommended targets, deintensifying (stopping or dose-reducing) diabetes medications rarely occurs.
To explore the perspectives of older adults with type 2 diabetes around deintensifying diabetes medications.
This qualitative study used individual semi-structured interviews, which included three clinical scenarios where deintensification may be indicated.
Twenty-four adults aged ≥65 years with medication-treated type 2 diabetes and hemoglobin A1c <7.5% were included (to thematic saturation) using a maximal variation sampling strategy for diabetes treatment and physician specialty.
Interviews were independently coded by two investigators and analyzed using a grounded theory approach. We identified major themes and subthemes and coded responses to the clinical scenarios as positive (in favor of deintensification), negative, or ambiguous.
Participants' mean age was 74 years, half were women, and 58% used a sulfonylurea or insulin. The first of four major themes was fear of losing control of diabetes, which participants weighed against the benefits of taking less medication (Theme 2). Few participants viewed glycemic control below target as a reason for deintensification and a majority would restart the medication if their home glucose increased. Some participants were anchored to their current diabetes treatment (Theme 3) driven by unrealistic views of medication benefits. A trusting patient-provider relationship (Theme 4) was a positive influence. In clinical scenarios, 8%, 4%, and 75% of participants viewed deintensification positively in the setting of poor health, limited life expectancy, and high hypoglycemia risk, respectively.
Optimizing deintensification requires patient education that describes both individualized glycemic targets and how they will change over the lifespan. Deintensification is an opportunity for shared decision-making, but providers must understand patients' beliefs about their medications and address misconceptions. Hypoglycemia prevention may be a helpful framing for discussing deintensification.
许多患有 2 型糖尿病的老年人的血糖控制已经达到了超出指南推荐目标的严格标准，但很少有患者会减少（停止或减少剂量）糖尿病药物的使用。
探讨年龄较大的 2 型糖尿病患者对减少糖尿病药物的看法。
本定性研究采用个体半结构化访谈，其中包括三种可能需要减少糖尿病药物的临床情况。
共纳入 24 名年龄≥65 岁、接受药物治疗的 2 型糖尿病且糖化血红蛋白（HbA1c）＜7.5%的患者（使用最大变异抽样策略纳入了不同糖尿病治疗方案和医生专业背景的患者，直到达到主题饱和）。
由两名研究人员独立对访谈进行编码，并使用扎根理论方法进行分析。我们确定了主要主题和子主题，并对临床情况的回答进行了编码，分为赞成（支持减少药物剂量）、反对和不确定。
参与者的平均年龄为 74 岁，其中一半为女性，58%使用磺脲类药物或胰岛素。四个主要主题中的第一个是对失去对糖尿病控制的恐惧，患者权衡了减少药物使用的好处（主题 2）。很少有参与者认为目标以下的血糖控制是减少药物剂量的原因，如果他们的家庭血糖升高，大多数人会重新开始服用药物。一些参与者受当前的糖尿病治疗方案（主题 3）的影响，这是由对药物益处的不切实际的看法驱动的。信任的医患关系（主题 4）是一个积极的影响因素。在临床情况下，分别有 8%、4%和 75%的参与者在健康状况不佳、预期寿命有限和低血糖风险高的情况下对减少药物剂量持积极态度。
优化减少药物剂量需要对患者进行教育，既要描述个体化的血糖目标，也要描述这些目标如何随患者的寿命而变化。减少药物剂量是进行共同决策的机会，但医务人员必须了解患者对药物的看法，并解决误解。预防低血糖可能是讨论减少药物剂量的一个有用框架。
