De-intensification of treatment for older adults from an interdisciplinary perspective

Abstract

We all know that there is strong evidence regarding the initiation, intensification, or modification of treatments. However, recommendations for reducing treatment intensity are lacking, especially in diabetes. Successful treatment intensity reduction, decreases polypharmacy and the risk of adverse effects. Discontinuation of hypoglycemic agents, statins, antihypertensives, and uric acid-lowering agents may be feasible in selected patients, but regular follow-up is important. Knowing when to reduce treatment intensity could prevent potential long-term adverse effects of therapy¹.

Unfortunately, there is no standardized approach to de-intensification, but one suggested strategy is to gradually discontinue medications, starting with sulfonylureas and transitioning to metformin and dipeptidyl peptidase-4 (DPP-4) inhibitors in frail patients^2-3. The primary indication for de-intensification should be the risk of hypoglycemia, rather than adherence to conventional glycemic targets³. Before initiating any treatment, it is advisable to calculate life expectancy to effectively guide clinical decisions. In cases where life expectancy is short, intensive treatment may not be beneficial².

The 4S study offers strategies for reducing the medication burden in older adults⁴. This document, published by the International Society for Geriatric Diabetes in May 2023, analyzed the optimization of diabetes treatment regimens in older adults: the role of reducing, de-intensifying, and simplifying treatments. To this end, they designed the 4S pathway, a series of four practical algorithms that enable healthcare professionals to ensure the optimal balance between therapeutic benefit and risk for each older person. This pathway consists of: step 1: identifying triggers; step 2: shared decision-making; step 3: setting and readjusting goals; and step 4: simpler and safer medications. Its aim is to help healthcare professionals identify changes in the clinical and functional status of older adults (cognitive, physical agility), lifestyle, social factors, available support, and personal preferences, and to determine, through shared decision-making with the patient and other professionals, an approach for establishing the treatment modifications that should be made. It should be noted that this guide is not intended for older people with diabetes who have their disease well controlled, but for those who are experiencing difficulties with their current approach to glycemic control.