Sometimes too much of a good thing is not so good. Such is the case with intensive glycemic control in certain populations.
Saturday’s symposium Overtreatment in Diabetes Management will examine the latest research and new tools to help clinicians make better decisions for their patients with type 2 diabetes. The two-hour symposium begins at 1:45 p.m. in room 6CF.
Sandeep Vijan, MD, MS, Professor of Internal Medicine at the University of Michigan, will open the session with a presentation titled “The Science of Personalized Diabetes Management—Do Benefits of Glycemic Therapy Vary among Different Patients?” Dr. Vijan’s research interests include identifying and implementing value-based interventions as a basis for health system reform with the primary goal of developing models to examine the costs, risks, and comparative effectiveness of personalized medicine for a variety of chronic diseases.
Rozalina G. McCoy, MD, MS, Assistant Professor of Medicine at Mayo Clinic, Rochester, Minnesota, will follow with a review of research examining the consequences of overtreatment.
“I’ll present data from multiple observational studies in a variety of populations that show that there’s a substantial fraction of patients with diabetes who are potentially overtreated,” Dr. McCoy said. “We’ve found that, too often, as we try to do the right thing for our patients and improve their diabetes control, we’ve done too much. Just like with many things, too much of a good thing can be harmful, both in the short term and in the long term.”
Dr. McCoy will discuss what constitutes overtreatment, how overtreatment can harm patients and increase their disease burden, and examine some of the reasons for overtreatment. Many of the studies she’ll discuss show that intensive treatment and potential overtreatment are common in routine clinical practice, disproportionately affecting older and more frail patients, and directly lead to increased risk of hypoglycemia. Specifically, there’s growing evidence that older patients with diabetes, as well as patients with dementia and chronic kidney disease who are at high risk for hypoglycemia, are often treated with insulin or sulfonylureas to achieve very low A1C levels, she said. This is particularly worrisome because patients with limited life expectancy are unlikely to derive long-term benefits from intensive glycemic control, but still face a high risk of immediate and potentially life-threatening harm from it, she said.
“In addition to the risk of hypoglycemia, there are other problems that can be caused by overtreatment,” Dr. McCoy said. “Overtreatment often entails using multiple glucose-lowering medications, which leads to polypharmacy, drug-drug interactions, medication side effects, and the high costs of purchasing those drugs.”
Dr. McCoy will also discuss the treatment burden on patients. The cost of multiple medications and remembering to take them are potential burdens that clinicians should consider when developing a treatment regimen, she said.
“I hope that patients, clinicians, and everyone caring for people with diabetes recognize overtreatment when it happens and see it as an important and avoidable problem,” Dr. McCoy said. “And I hope that this recognition will lead all of us to reexamine our practice and feel more comfortable deintensifying therapy when appropriate, especially in high-risk elderly and frail patients who not only face the high risk of hypoglycemia with intensive treatment, but also stand to gain the least from intensive glycemic control.”
During the next presentation, Deborah J. Wexler, MD, will dive deeper into the mechanics of personalized diabetes care.
Using the American Diabetes Association’s Standards of Care as a framework, Dr. Wexler will review recent clinical trials that help clinicians individualize treatment in special populations, including people with diabetes and cardiovascular disease and people with diabetes and nonalcoholic fatty liver disease.
“The Standards of Care approach to glycemic management is a very useful framework as a starting point for individualizing treatment,” said Dr. Wexler, but she noted that it can’t definitively answer how to personalize treatment in the real world.
However, more help is on the way. The National Institute of Diabetes and Digestive and Kidney Diseases’ ongoing Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness (GRADE) Study, which will be reporting in 2021, is expected to provide further guidance on individualized treatment regimens.
In the meantime, a handful of recent trials also provide some guidance, noted Dr. Wexler, Associate Clinical Chief in Massachusetts General Hospital’s Diabetes Unit and Co-clinical Director of the hospital’s Diabetes Center. She will review evidence from several trials to highlight how clinicians can individualize care for specific populations.
“For example, the recent publication of the LEADER trial and the EMPA-REG trial can help us think about specific glycemic management approaches in people with pre-existing cardiovascular disease,” Dr. Wexler said. “And there was a recent study on the use of pioglitazone in people with NASH [nonalcoholic steatohepatitis] and prediabetes or type 2 diabetes that showed benefit of pioglitazone, which is a drug that had fallen into disfavor but may in fact be useful for that population.”
During the session’s last presentation, Elbert S. Huang MD, MPH, FACP, will review results of a University of Chicago study into an intervention tool to aid shared decision making.
“I’m going describe an ADA-funded intervention that we designed, implemented, and pilot-tested that was designed to get older patients involved in their goal-setting and to include a patient’s prognosis and preferences in decisions around goal setting,” said Dr. Huang, Associate Professor of Medicine at the University of Chicago.
The intervention included a website that patients used before a clinic visit that educated them on the goals of their diabetes care, elicited their preferences for treatments and the intensity of treatments, and gathered information that fed into a simulation model within the website that generated personalized estimates of risk.
“We used the shared decision making principles, but we merged it with prognostic modeling, which is really unusual,” Dr. Huang said. “However, it’s not always clear if decision aids will lead to more aggressive therapy. Sometimes patients want more aggressive therapy despite the fact that you want to push them toward less aggressive therapy. Sometimes patients will choose less aggressive therapy when they should have more aggressive therapy.”
The results from the study were surprising, said Dr. Huang, noting that the intervention did not include guidance for the patient or the physician about what the treatment guidelines suggest based on risk.
“The intervention did encourage more discussions with doctors about goals, and more patients had their doctors believing that they knew their goals after the intervention,” he said. “But the direction in which the goals shifted was unexpected. When patients saw their risk prediction, they actually chose more intensive goals.”