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Diabetes Drug Dosing May Be Too High in Older Adults

With commentary by Tanner Caverly, M.D., MPH, clinical lecturer and lead author on the primary care provider survey from the University of Michigan.

If you're over age 70 and taking medication to treat high blood sugar or blood pressure, you may be getting more medicine than you need.

Researchers at the University of Michigan checked the health records of 211,667 adults over age 70 with type 1 or type 2 diabetes and high blood pressure. They found that among those who could have had their medication doses lowered because their blood pressure and/or blood sugar levels were low, just 1 in 4 did.

CDE and diabetes medication The study was published in the December 2015 issue of JAMA Internal Medicine.

Age-related changes in the way the body breaks down and eliminates medications are a big reason doses that were once right can become too much through the years, leading to too-low blood pressure and blood sugar. This can raise risk for dizzy spells, confusion, weakness, falls and even death.1

After testing patients, the results revealed how many people may be at risk. Twenty percent of volunteers had blood sugar levels that were low (an A1C of 6.0-6.4%) or extremely low (an A1C below 6%)—a red flag for a medication review. But just 27% with low numbers and 27% with extremely low A1cs had their medicines cut back.

Meanwhile, half of the study participants had low blood pressure (a systolic, or top number, of 120-129 or a diastolic, or bottom number, below 65) or extremely low blood pressure (a reading below 120/65). Yet just 16 to 19% had their blood pressure drug regimens changed as a result.

In a related study, also published in the December 2015 JAMA, the researchers surveyed 600 physicians, nurse practitioners and physician assistants to find out how they would handle the case of a 77-year-old man taking diabetes drugs who had extremely low blood sugar. Just 38% of healthcare providers said “de-intensifying” medication would help when they were presented with the hypothetical case of the elderly man with diabetes and low blood sugar. Almost half said they wouldn’t worry and 42% admitted they were concerned they would receive negative performance ratings if the man’s blood sugar rose. One in four said they also worried about malpractice lawsuits.

Think it may be time to have your doctor review—and possibly reduce—doses of medications for high blood sugar and high blood pressure? You may have to bring it up yourself at your next health appointment. Just half of the health practitioners surveyed in the second study said they would cut back on medication. The main reason: Doctors worry that easing up on treatment will lead to high blood sugar and high blood pressure, the researchers found.

“Physicians are used to thinking about when to start medications, and if a patient isn’t complaining and appears to be doing fine, stopping medications may not be first thing on their mind,” Tanner Caverly, M.D., MPH, clinical lecturer and lead author on the survey of primary care providers noted in a press release from the University of Michigan. “As we get more precise evidence about the degree of benefit and harm from using these medications, it’s showing us that we need to dial back in some patients.”

The right target: new territory

But hitting the right numbers in older people isn’t always easy. In an editorial published with the studies, an expert from Italy’s University of Florence noted that there’s not much research yet on what happens when medication levels are lowered in older people.

Still, some groups are recommending ways to get started. According to the American Board of Internal Medicine’s Choosing Wisely campaign, medication should not be used to reduce blood sugar levels below an A1C of 7% in most adults age 65 years or older.2 American Diabetes Association guidelines call an A1c below 7.5 to 8.0% acceptable in older people – and that keeping numbers below 8.5% is reasonable in people with very poor health or limited life expectancy.And recent, national blood pressure guidelines recommend aiming for a systolic blood pressure reading below 149 for older people who take blood pressure drugs, rather than pushing it below 140.5.4

Track your own numbers

DiabeticLifetsyle Medical Advisory Board Member Caroline Apovian MD, FACP, FACN, professor of medicine and pediatrics in the section of endocrinology, diabetes, and nutrition at Boston University School of Medicine, who was not involved in the study, says older people and their families should stay alert to signs of low blood sugar and low blood pressure. “The best way to stay on top of this is by monitoring blood sugar and blood pressure regularly at home,” says Dr. Apovian. “You should always call your doctor if blood sugars are consistently 110 or less or your blood pressure is consistently less than 120/80.”

Diet changes could also turn a medication dose that’s worked well in the past into one that suddenly torpedoes blood sugar. “Older people may not have the same urge to eat, yet may be taking the same amount of medications that can cause low blood sugar such as insulin or a sulfonylurea,” she explains. “Switching to medications that do not cause hypoglycemia, such as GLP1 analogs [such as exenatide (Byetta), liraglutide (Victoza), and others] or SGLT2 inhibitors [such as canagliflozin (Invokana), empagliflozin (Jardiance) and others] could help. It’s a good idea to discuss the best targets with your endocrinologist, family doctor or geriatrician.”

Updated on: July 26, 2017
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