As Simon discussed in our blog last week, there has been real concern that one of the many groups impacted (both directly and indirectly) as a result of the pandemic are those with diabetes. Inevitably diabetic monitoring has taken a massive hit over the past 15 months, and I’m sure all practices around the country are doing their utmost to catch up on the backlog of reviews. However, as Simon also eluded to, this is no easy task with Primary Care in the UK facing overwhelming demand and exhausted clinicians. So prioritisation will be crucial. We need to ‘box smart’. We need to focus our time and energy where it will be of most value, and importantly not over-treat people who will not benefit, or indeed where that treatment may lead to unnecessary harm.
The push for ‘treatment to target’ in diabetes over the past decade has clearly brought improved outcomes for many people. But I have always been concerned that this drive, especially with the advent of published audit data and benchmarking, runs the risk of over-treatment in some people. It’s quite hard to stand firm and not add in another drug, with questionable benefit, in the face of a pop-up QoF box telling you to intensify treatment. This is never more apparent than in our older, frailer populations. Indeed we have evidence that more intensive treatment in older, frailer people with diabetes leads to increased treatment burdens, worse quality of life, and runs the risk of hypoglycaemia and poorer outcomes.
Further evidence to support this issue came in the form of an observational study from Canada, published last month (Diabetologia 2021 May;64(5):1093-1102. doi: 10.1007/s00125-020-05370-7). It was a retrospective cohort study of over 100,000 community-dwelling older adults with diabetes aged ≥75 (mean age ~80). They were categorised as having intensive or conservative glycaemic control (HbA1c <53 mmol/mol [<7%] or 54-69 mmol/mol [7.1-8.5%], respectively), and as undergoing treatment with high-risk (i.e. insulin, sulfonylureas) or low-risk (other) agents. Over 20% were treated to an intensive target with high-risk drugs and in that group there was a 50% increased risk of the composite outcome (hospitalisation, A&E visit and death) compared to those treated with lower risk drugs to a conservative target.
This evidence very much supports the current joint American/European guidance which highlights the importance of individualised targets (not blanket targets), that treatment burdens (which includes monitoring and follow-up) should be carefully considered at all stages, and that if there is a need to minimise hypoglycaemia (e.g. in the older, frail adult), sulphonylureas and insulin should generally be avoided. So yes, there will be many people with diabetes who are overdue treatment escalation and more intensive follow-up, but equally there will be some older, frailer patients who will benefit from treatment reductions, and less intensive follow-up - this will improve their quality of life, reduce hypoglycaemia risk (possibly saving them a hospital admission) and free up appointment time for other people.
So if you need a quick re-fresher on managing diabetes in the older adult why not do our new KISS Quiz: Diabetes in the older person, recently published in our CPD module section in the NB Dashboard- a quick 30-minute update with MCQs, which includes excellent guidance on Hba1c targets, and also recommendations on de-escalation thresholds and when to de-prescribe in frailer adults. And if you’re in need of the full package please do join Sarah and Su this Saturday 12th June for the fully interactive live webinar on Diabetes