A recent study has shed light on the changing dynamics of diabetes care among elderly patients nearing the end of life. Conducted on 975,407 Medicare beneficiaries with type 2 diabetes (T2D) who died between January 2015 and December 2019, the study reveals significant shifts in medication usage as patients approached death. The mean age at death was 80.9 years, with women comprising 54.3% of the participants. Led by Dr. Alexander Kutz from Brigham and Women’s Hospital and Harvard Medical School, the study underscores the need for reevaluation of diabetes management strategies in this vulnerable population.
The research, supported by the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women’s Hospital, used a validated claims-based frailty index to categorize participants based on their frailty levels. Findings indicate that the use of antidiabetes medications decreased from 66.1% in the 9 to 12 months before death to 60.8% in the last four months of life. This decrease primarily stemmed from reduced usage of metformin and sulfonylureas.
Interestingly, while the overall use of antidiabetes medications declined, the study observed an increase in the use of short-acting and long-acting insulin agents as death approached. Short-acting insulin use rose from 28.0% to 32.9%, and long-acting insulin usage increased from 41.2% to 43.9%. Notably, frailer individuals demonstrated a more significant uptick in insulin use.
Despite these changes towards end-of-life care, there was a slight increase in the proportion of older patients receiving antidiabetes medications over the study period, from 71.4% in 2015 to 72.9% in 2019. Metformin usage showed the most substantial rise, increasing from 40.7% to 46.5%, while sulfonylureas saw a decline from 37.0% to 31.8%.
The study accounted for all available medication classes during its period, including dipeptidyl peptidase-4 inhibitors, glucagon-like peptide 1 (GLP-1) receptor agonists, sodium-glucose cotransporter-2 (SGLT2) inhibitors, and other medications. This comprehensive approach highlighted the complexity of medication management in elderly patients with T2D.
“The study findings underscore important implications for diabetes management in patients nearing the end of life. With ~70% of patients with T2D using at least one antidiabetes medication, there is a need to consider further de-escalation or deprescribing in this vulnerable population,” – The authors
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