A Cross-Sectional Study of Overtreatment and Deintensification of Antidiabetic and Antihypertensive Medications in Diabetes Mellitus: The TEMD Overtreatment Study
Introduction Targeting better glycated hemoglobin (HbA1c) and blood pressure (BP) goals may endanger older adults with type 2 diabetes mellitus (T2DM). Overtreatment of T2DM and hypertension is a trending issue, although undertreatment is still common. We investigated the rates and predictors of ove...
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Published in | Diabetes therapy Vol. 11; no. 5; pp. 1045 - 1059 |
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Main Authors | , , , , , , , , , , , |
Format | Journal Article |
Language | English |
Published |
Cheshire
Springer Healthcare
01.05.2020
Springer Nature B.V |
Subjects | |
Online Access | Get full text |
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Abstract | Introduction
Targeting better glycated hemoglobin (HbA1c) and blood pressure (BP) goals may endanger older adults with type 2 diabetes mellitus (T2DM). Overtreatment of T2DM and hypertension is a trending issue, although undertreatment is still common. We investigated the rates and predictors of overtreatment and undertreatment of glycemia and BP in older adults with T2DM and physicians’ attitudes to deintensify or intensify treatment.
Methods
Data from older adults (≥ 65 years) enrolled in a large nationwide T2DM survey in 2017 across Turkey were analyzed. Overtreatment of glycemia was defined as HbA1c < 6.5% plus the use of ≥ 2 oral antihyperglycemics or insulin, and BP overtreatment was defined as systolic BP (SBP) < 120 mmHg or diastolic BP (DBP) < 65 mmHg plus the use of ≥ 2 drugs. Undertreatment of glycemia was defined as HbA1c > 9%, and BP undertreatment was defined as SBP > 150 mmHg or DBP > 90 mmHg. Deintensification or intensification rates were calculated according to treatment modification initiated by the treating physician(s).
Results
The rate of overtreatment in the glycemia group (
n
= 1264) was 9.8% (
n
= 124) and that in the BP group (
n
= 1052) was 7.3% (
n
= 77), whereas the rate of undertreatment was 14.2% (
n
= 180) and 15.2% (
n
= 160), respectively. In the adjusted model, use of oral secretagogues (sulfonylureas or glinides) (odds ratio [OR] 1.94, 95% confidence interval [CI] 1.2–3.1) and follow-up at a private clinic (OR 1.81, 95% CI 1.0–3.3) were predictors of glycemia overtreatment. BP overtreatment was independently associated with the use insulin-based diabetes therapies (OR 1.86, 95% CI 1.14–3.04). There was no independent association of BP undertreatment to the study confounders. The deintensification and intensification rates were 25 and 75.6%, respectively, for glycemia and 10.9 and 9.2%, respectively, for BP.
Conclusions
The results show that one in ten older adults with T2DM are overtreated while one in four require modification of their current antihyperglycemic and antihypertensive treatments. Physicians are eager to intensify medications while they largely ignore deintensification in diabetes management. These results warrant enforced measures to improve the care of older adults with T2DM.
Trial Registration
ClinicalTrials.gov identifier, NCT 03455101.
Plain Language Summary
Type 2 diabetes mellitus (T2DM) is prevalent in the elderly population. Strict glycemia and blood pressure (BP) targets do not improve outcomes but they may increase the rate of adverse events in these patients. Consequently, overtreatment has been an emerging issue in recent years. The overall magnitude of the problem is largely unknown. Therefore, we assessed the rates and predictors of overtreatment and undertreatment of blood glucose and BP in Turkish older adults with T2DM. We also investigated physicians’ reactions to treatment modulation in the overtreated or undertreated patients. Patients participating in the study were: older adults (
n
= 1264) with T2DM from a cross-sectional, nationwide, multicenter study who followed-up at the same unit during the past 12 months and who did not have decompensated liver disease, psychiatric disorders interfering with cognition or compliance, bariatric surgery in the past 12 months or renal replacement therapy. We found that:
One of ten older adults with T2DM were overtreated for glycemia.
One in four older adults with T2DM required modification of antihyperglycemic treatment with inclusion of the number of insufficiently treated individuals.
One in four older adults with T2DM required modification of antihypertensive treatment.
Physicians are much more inclined to intensify antihyperglycemia medications, while they largely ignore the need for deintensification in the overtreated patients.
Physicians did not modify antihypertensive treatments in about 90% of patients with uncontrolled BP.
Patients who were treated by oral secretagogues and followed in private clinics were most prone to glycemia overtreatment.
Patients who were treated by insulin-based regiments were prone to BP overtreatment.
These results suggest that measures should be taken to improve physician awareness of drug modification in older patients with T2DM. |
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AbstractList | Introduction
Targeting better glycated hemoglobin (HbA1c) and blood pressure (BP) goals may endanger older adults with type 2 diabetes mellitus (T2DM). Overtreatment of T2DM and hypertension is a trending issue, although undertreatment is still common. We investigated the rates and predictors of overtreatment and undertreatment of glycemia and BP in older adults with T2DM and physicians’ attitudes to deintensify or intensify treatment.
Methods
Data from older adults (≥ 65 years) enrolled in a large nationwide T2DM survey in 2017 across Turkey were analyzed. Overtreatment of glycemia was defined as HbA1c < 6.5% plus the use of ≥ 2 oral antihyperglycemics or insulin, and BP overtreatment was defined as systolic BP (SBP) < 120 mmHg or diastolic BP (DBP) < 65 mmHg plus the use of ≥ 2 drugs. Undertreatment of glycemia was defined as HbA1c > 9%, and BP undertreatment was defined as SBP > 150 mmHg or DBP > 90 mmHg. Deintensification or intensification rates were calculated according to treatment modification initiated by the treating physician(s).
Results
The rate of overtreatment in the glycemia group (
n
= 1264) was 9.8% (
n
= 124) and that in the BP group (
n
= 1052) was 7.3% (
n
= 77), whereas the rate of undertreatment was 14.2% (
n
= 180) and 15.2% (
n
= 160), respectively. In the adjusted model, use of oral secretagogues (sulfonylureas or glinides) (odds ratio [OR] 1.94, 95% confidence interval [CI] 1.2–3.1) and follow-up at a private clinic (OR 1.81, 95% CI 1.0–3.3) were predictors of glycemia overtreatment. BP overtreatment was independently associated with the use insulin-based diabetes therapies (OR 1.86, 95% CI 1.14–3.04). There was no independent association of BP undertreatment to the study confounders. The deintensification and intensification rates were 25 and 75.6%, respectively, for glycemia and 10.9 and 9.2%, respectively, for BP.
Conclusions
The results show that one in ten older adults with T2DM are overtreated while one in four require modification of their current antihyperglycemic and antihypertensive treatments. Physicians are eager to intensify medications while they largely ignore deintensification in diabetes management. These results warrant enforced measures to improve the care of older adults with T2DM.
Trial Registration
ClinicalTrials.gov identifier, NCT 03455101.
Plain Language Summary
Type 2 diabetes mellitus (T2DM) is prevalent in the elderly population. Strict glycemia and blood pressure (BP) targets do not improve outcomes but they may increase the rate of adverse events in these patients. Consequently, overtreatment has been an emerging issue in recent years. The overall magnitude of the problem is largely unknown. Therefore, we assessed the rates and predictors of overtreatment and undertreatment of blood glucose and BP in Turkish older adults with T2DM. We also investigated physicians’ reactions to treatment modulation in the overtreated or undertreated patients. Patients participating in the study were: older adults (
n
= 1264) with T2DM from a cross-sectional, nationwide, multicenter study who followed-up at the same unit during the past 12 months and who did not have decompensated liver disease, psychiatric disorders interfering with cognition or compliance, bariatric surgery in the past 12 months or renal replacement therapy. We found that:
One of ten older adults with T2DM were overtreated for glycemia.
One in four older adults with T2DM required modification of antihyperglycemic treatment with inclusion of the number of insufficiently treated individuals.
One in four older adults with T2DM required modification of antihypertensive treatment.
Physicians are much more inclined to intensify antihyperglycemia medications, while they largely ignore the need for deintensification in the overtreated patients.
Physicians did not modify antihypertensive treatments in about 90% of patients with uncontrolled BP.
Patients who were treated by oral secretagogues and followed in private clinics were most prone to glycemia overtreatment.
Patients who were treated by insulin-based regiments were prone to BP overtreatment.
These results suggest that measures should be taken to improve physician awareness of drug modification in older patients with T2DM. Targeting better glycated hemoglobin (HbA1c) and blood pressure (BP) goals may endanger older adults with type 2 diabetes mellitus (T2DM). Overtreatment of T2DM and hypertension is a trending issue, although undertreatment is still common. We investigated the rates and predictors of overtreatment and undertreatment of glycemia and BP in older adults with T2DM and physicians' attitudes to deintensify or intensify treatment. Data from older adults (≥ 65 years) enrolled in a large nationwide T2DM survey in 2017 across Turkey were analyzed. Overtreatment of glycemia was defined as HbA1c < 6.5% plus the use of ≥ 2 oral antihyperglycemics or insulin, and BP overtreatment was defined as systolic BP (SBP) < 120 mmHg or diastolic BP (DBP) < 65 mmHg plus the use of ≥ 2 drugs. Undertreatment of glycemia was defined as HbA1c > 9%, and BP undertreatment was defined as SBP > 150 mmHg or DBP > 90 mmHg. Deintensification or intensification rates were calculated according to treatment modification initiated by the treating physician(s). The rate of overtreatment in the glycemia group (n = 1264) was 9.8% (n = 124) and that in the BP group (n = 1052) was 7.3% (n = 77), whereas the rate of undertreatment was 14.2% (n = 180) and 15.2% (n = 160), respectively. In the adjusted model, use of oral secretagogues (sulfonylureas or glinides) (odds ratio [OR] 1.94, 95% confidence interval [CI] 1.2-3.1) and follow-up at a private clinic (OR 1.81, 95% CI 1.0-3.3) were predictors of glycemia overtreatment. BP overtreatment was independently associated with the use insulin-based diabetes therapies (OR 1.86, 95% CI 1.14-3.04). There was no independent association of BP undertreatment to the study confounders. The deintensification and intensification rates were 25 and 75.6%, respectively, for glycemia and 10.9 and 9.2%, respectively, for BP. The results show that one in ten older adults with T2DM are overtreated while one in four require modification of their current antihyperglycemic and antihypertensive treatments. Physicians are eager to intensify medications while they largely ignore deintensification in diabetes management. These results warrant enforced measures to improve the care of older adults with T2DM. ClinicalTrials.gov identifier, NCT03455101. IntroductionTargeting better glycated hemoglobin (HbA1c) and blood pressure (BP) goals may endanger older adults with type 2 diabetes mellitus (T2DM). Overtreatment of T2DM and hypertension is a trending issue, although undertreatment is still common. We investigated the rates and predictors of overtreatment and undertreatment of glycemia and BP in older adults with T2DM and physicians’ attitudes to deintensify or intensify treatment.MethodsData from older adults (≥ 65 years) enrolled in a large nationwide T2DM survey in 2017 across Turkey were analyzed. Overtreatment of glycemia was defined as HbA1c < 6.5% plus the use of ≥ 2 oral antihyperglycemics or insulin, and BP overtreatment was defined as systolic BP (SBP) < 120 mmHg or diastolic BP (DBP) < 65 mmHg plus the use of ≥ 2 drugs. Undertreatment of glycemia was defined as HbA1c > 9%, and BP undertreatment was defined as SBP > 150 mmHg or DBP > 90 mmHg. Deintensification or intensification rates were calculated according to treatment modification initiated by the treating physician(s).ResultsThe rate of overtreatment in the glycemia group (n = 1264) was 9.8% (n = 124) and that in the BP group (n = 1052) was 7.3% (n = 77), whereas the rate of undertreatment was 14.2% (n = 180) and 15.2% (n = 160), respectively. In the adjusted model, use of oral secretagogues (sulfonylureas or glinides) (odds ratio [OR] 1.94, 95% confidence interval [CI] 1.2–3.1) and follow-up at a private clinic (OR 1.81, 95% CI 1.0–3.3) were predictors of glycemia overtreatment. BP overtreatment was independently associated with the use insulin-based diabetes therapies (OR 1.86, 95% CI 1.14–3.04). There was no independent association of BP undertreatment to the study confounders. The deintensification and intensification rates were 25 and 75.6%, respectively, for glycemia and 10.9 and 9.2%, respectively, for BP.ConclusionsThe results show that one in ten older adults with T2DM are overtreated while one in four require modification of their current antihyperglycemic and antihypertensive treatments. Physicians are eager to intensify medications while they largely ignore deintensification in diabetes management. These results warrant enforced measures to improve the care of older adults with T2DM.Trial RegistrationClinicalTrials.gov identifier, NCT 03455101.Plain Language SummaryType 2 diabetes mellitus (T2DM) is prevalent in the elderly population. Strict glycemia and blood pressure (BP) targets do not improve outcomes but they may increase the rate of adverse events in these patients. Consequently, overtreatment has been an emerging issue in recent years. The overall magnitude of the problem is largely unknown. Therefore, we assessed the rates and predictors of overtreatment and undertreatment of blood glucose and BP in Turkish older adults with T2DM. We also investigated physicians’ reactions to treatment modulation in the overtreated or undertreated patients. Patients participating in the study were: older adults (n = 1264) with T2DM from a cross-sectional, nationwide, multicenter study who followed-up at the same unit during the past 12 months and who did not have decompensated liver disease, psychiatric disorders interfering with cognition or compliance, bariatric surgery in the past 12 months or renal replacement therapy. We found that:One of ten older adults with T2DM were overtreated for glycemia.One in four older adults with T2DM required modification of antihyperglycemic treatment with inclusion of the number of insufficiently treated individuals.One in four older adults with T2DM required modification of antihypertensive treatment.Physicians are much more inclined to intensify antihyperglycemia medications, while they largely ignore the need for deintensification in the overtreated patients.Physicians did not modify antihypertensive treatments in about 90% of patients with uncontrolled BP.Patients who were treated by oral secretagogues and followed in private clinics were most prone to glycemia overtreatment.Patients who were treated by insulin-based regiments were prone to BP overtreatment.These results suggest that measures should be taken to improve physician awareness of drug modification in older patients with T2DM. Type 2 diabetes mellitus (T2DM) is prevalent in the elderly population. Strict glycemia and blood pressure (BP) targets do not improve outcomes but they may increase the rate of adverse events in these patients. Consequently, overtreatment has been an emerging issue in recent years. The overall magnitude of the problem is largely unknown. Therefore, we assessed the rates and predictors of overtreatment and undertreatment of blood glucose and BP in Turkish older adults with T2DM. We also investigated physicians’ reactions to treatment modulation in the overtreated or undertreated patients. Patients participating in the study were: older adults ( n = 1264) with T2DM from a cross-sectional, nationwide, multicenter study who followed-up at the same unit during the past 12 months and who did not have decompensated liver disease, psychiatric disorders interfering with cognition or compliance, bariatric surgery in the past 12 months or renal replacement therapy. We found that: One of ten older adults with T2DM were overtreated for glycemia. One in four older adults with T2DM required modification of antihyperglycemic treatment with inclusion of the number of insufficiently treated individuals. One in four older adults with T2DM required modification of antihypertensive treatment. Physicians are much more inclined to intensify antihyperglycemia medications, while they largely ignore the need for deintensification in the overtreated patients. Physicians did not modify antihypertensive treatments in about 90% of patients with uncontrolled BP. Patients who were treated by oral secretagogues and followed in private clinics were most prone to glycemia overtreatment. Patients who were treated by insulin-based regiments were prone to BP overtreatment. These results suggest that measures should be taken to improve physician awareness of drug modification in older patients with T2DM. INTRODUCTIONTargeting better glycated hemoglobin (HbA1c) and blood pressure (BP) goals may endanger older adults with type 2 diabetes mellitus (T2DM). Overtreatment of T2DM and hypertension is a trending issue, although undertreatment is still common. We investigated the rates and predictors of overtreatment and undertreatment of glycemia and BP in older adults with T2DM and physicians' attitudes to deintensify or intensify treatment. METHODSData from older adults (≥ 65 years) enrolled in a large nationwide T2DM survey in 2017 across Turkey were analyzed. Overtreatment of glycemia was defined as HbA1c < 6.5% plus the use of ≥ 2 oral antihyperglycemics or insulin, and BP overtreatment was defined as systolic BP (SBP) < 120 mmHg or diastolic BP (DBP) < 65 mmHg plus the use of ≥ 2 drugs. Undertreatment of glycemia was defined as HbA1c > 9%, and BP undertreatment was defined as SBP > 150 mmHg or DBP > 90 mmHg. Deintensification or intensification rates were calculated according to treatment modification initiated by the treating physician(s). RESULTSThe rate of overtreatment in the glycemia group (n = 1264) was 9.8% (n = 124) and that in the BP group (n = 1052) was 7.3% (n = 77), whereas the rate of undertreatment was 14.2% (n = 180) and 15.2% (n = 160), respectively. In the adjusted model, use of oral secretagogues (sulfonylureas or glinides) (odds ratio [OR] 1.94, 95% confidence interval [CI] 1.2-3.1) and follow-up at a private clinic (OR 1.81, 95% CI 1.0-3.3) were predictors of glycemia overtreatment. BP overtreatment was independently associated with the use insulin-based diabetes therapies (OR 1.86, 95% CI 1.14-3.04). There was no independent association of BP undertreatment to the study confounders. The deintensification and intensification rates were 25 and 75.6%, respectively, for glycemia and 10.9 and 9.2%, respectively, for BP. CONCLUSIONSThe results show that one in ten older adults with T2DM are overtreated while one in four require modification of their current antihyperglycemic and antihypertensive treatments. Physicians are eager to intensify medications while they largely ignore deintensification in diabetes management. These results warrant enforced measures to improve the care of older adults with T2DM. TRIAL REGISTRATIONClinicalTrials.gov identifier, NCT03455101. |
Author | Sonmez, Alper Gul, Kamile Ozturk, Feyza Yener Demirci, Ibrahim Tasci, Ilker Barcin, Cem Cetinkalp, Sevki Sabuncu, Tevfik Haymana, Cem Aydin, Hasan Bayram, Fahri Satman, Ilhan |
Author_xml | – sequence: 1 givenname: Alper orcidid: 0000-0002-9309-7715 surname: Sonmez fullname: Sonmez, Alper email: alpersonmez@yahoo.com organization: Department of Endocrinology and Metabolism, Gulhane School of Medicine, University of Health Sciences – sequence: 2 givenname: Ilker surname: Tasci fullname: Tasci, Ilker organization: Department of Internal Medicine, Gulhane School of Medicine, University of Health Sciences – sequence: 3 givenname: Ibrahim surname: Demirci fullname: Demirci, Ibrahim organization: Department of Endocrinology and Metabolism, Gulhane Training and Research Hospital, University of Health Sciences – sequence: 4 givenname: Cem surname: Haymana fullname: Haymana, Cem organization: Department of Endocrinology and Metabolism, Gulhane Training and Research Hospital, University of Health Sciences – sequence: 5 givenname: Cem surname: Barcin fullname: Barcin, Cem organization: Department of Cardiology, Gulhane School of Medicine, University of Health Sciences – sequence: 6 givenname: Hasan surname: Aydin fullname: Aydin, Hasan organization: Department of Endocrinology and Metabolism, School of Medicine, Yeditepe University – sequence: 7 givenname: Sevki surname: Cetinkalp fullname: Cetinkalp, Sevki organization: Department of Endocrinology and Metabolism, School of Medicine, Ege University – sequence: 8 givenname: Feyza Yener surname: Ozturk fullname: Ozturk, Feyza Yener organization: Department of Endocrinology and Metabolism, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences – sequence: 9 givenname: Kamile surname: Gul fullname: Gul, Kamile organization: Department of Endocrinology and Metabolism, School of Medicine, Sutcu Imam University – sequence: 10 givenname: Tevfik surname: Sabuncu fullname: Sabuncu, Tevfik organization: Department of Endocrinology and Metabolism, School of Medicine, Harran University – sequence: 11 givenname: Ilhan surname: Satman fullname: Satman, Ilhan organization: Department of Endocrinology and Metabolism, School of Medicine, Istanbul University – sequence: 12 givenname: Fahri surname: Bayram fullname: Bayram, Fahri organization: Department of Endocrinology and Metabolism, School of Medicine, Erciyes University |
BackLink | https://www.ncbi.nlm.nih.gov/pubmed/32088879$$D View this record in MEDLINE/PubMed |
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ContentType | Journal Article |
Contributor | Dogru, Teoman Akbas, Emin Murat Demirbas, Berrin Bozkirli, Emre Durmus, Elif Tutku Topsakal, Senay Cakal, Erman Selek, Alev Kucukler, Ferit Kerim Carlioglu, Ayse Kargılı Kebapci, Nur Corapcioglu, Demet Corakci, Ahmet Baldane, Suleyman Kirik, Ali Hekimsoy, Zeliha Yaylali, Guzin Fidan Oz Gul, Ozen Dalkiran, Sefika Nuhoglu, Irfan Ozdemir, Didem Efe, Belgin Akbaba, Gulhan Dizdar, Oguzhan Sıtkı Kirac, Cem Onur Cetinarslan, Berrin Capoglu, İlyas Cesur, Mustafa Ersoz, Halil Onder Ayturk, Semra Yetkin, Ilhan Yildiz, Busra Salman, Serpil Eren, Mehmet Ali Kucuksarac Kiyici, Sinem Ucler, Rıfkı Haymana, Cem Cakir, Bekir Bayram, Fahri Altay, Mustafa Sendur, Suleyman Nahit Cakmak, Ramazan Yilmaz, Murat Cagiltay, Eylem Canlar, Sule Araz, Mustafa Deyneli, Oguzhan Saydam, Basak Ozgen Bascil Tutuncu, Neslihan Sonmez, Alper Yildiz, Okan Bulent Bayraktaroglu, Taner Dagdeviren, Murat Sahin, İbrahim Gurkan, Eren Mete, Turkan Kutlu, Mustafa Boysan, S Nur Unubol, Mustafa Hacisahinogullari, Hulya Cordan, Ilker Ertek, Sibel Akin, Safak Ozturk, Feyza Yener Dinccag, Nevin Yumu |
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Keywords | Type 2 diabetes Older adults Overtreatment Undertreatment Arterial blood pressure Glycemia |
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PublicationSubtitle | Research, treatment and education of diabetes and related disorders |
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Snippet | Introduction
Targeting better glycated hemoglobin (HbA1c) and blood pressure (BP) goals may endanger older adults with type 2 diabetes mellitus (T2DM).... Targeting better glycated hemoglobin (HbA1c) and blood pressure (BP) goals may endanger older adults with type 2 diabetes mellitus (T2DM). Overtreatment of... IntroductionTargeting better glycated hemoglobin (HbA1c) and blood pressure (BP) goals may endanger older adults with type 2 diabetes mellitus (T2DM).... INTRODUCTIONTargeting better glycated hemoglobin (HbA1c) and blood pressure (BP) goals may endanger older adults with type 2 diabetes mellitus (T2DM).... Type 2 diabetes mellitus (T2DM) is prevalent in the elderly population. Strict glycemia and blood pressure (BP) targets do not improve outcomes but they may... |
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StartPage | 1045 |
SubjectTerms | Antidiabetics Antihypertensives Blood pressure Cardiology Cross-sectional studies Diabetes Drug therapy Endocrinology Gastrointestinal surgery Insulin Internal Medicine Medicine Medicine & Public Health Older people Original Research Physicians |
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Title | A Cross-Sectional Study of Overtreatment and Deintensification of Antidiabetic and Antihypertensive Medications in Diabetes Mellitus: The TEMD Overtreatment Study |
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