Article,
Diabetes Deprescribing in Older Adults: A Randomized Clinical Trial
(2025)
DOI: 10.1001/jamainternmed.2025.2015
Abstract
Importance
Medication-related hypoglycemia is the leading cause of iatrogenic complications among older adults with type 2 diabetes.
Objective
To compare physician academic detailing (AD) with or without patient previsit activation for insulin and/or sulfonylurea deprescribing in older patients with diabetes.
Design, Setting, and Participants
This randomized clinical trial was conducted from September 2020 to March 2024 with 6 and 12 months of follow-up in a large integrated health care system in Northern California. Primary care physicians (PCPs) and their patients with type 2 diabetes who were 75 years and older, had hemoglobin A
1c
of 8.0\% or lower, and were treated with insulin and/or sulfonylureas were included.
Interventions
Participating PCPs attended at least 1 AD session that provided evidence to support diabetes medication reassessment and potential deprescribing strategies in older patients with type 2 diabetes. Prior to their visit with a participating PCP, trial patients were randomly assigned to receive either a previsit activation deprescribing handout (AD plus previsit arm) or an attention control healthy lifestyle handout (AD-only arm).
Main Outcomes and Measures
Primary outcomes (assessed at 6 months) were diabetes medication deprescribing (an aggregate measure) and any patient-reported severe hypoglycemia episodes.
Results
A total of 211 PCPs were able to attend at least 1 AD session and treated 450 eligible patients (mean SD age, 79.9 4.0 years; 223 49.6\% female; mean SD concurrent chronic conditions, 6.2 3.6; and mean SD hemoglobin A
1c
, 7.5\% 1.1\%). At 6 months, there was a statistically significant higher diabetes medication deprescribing rate in the AD plus previsit activation arm compared with the AD-only arm (36 of 232 patients 15.8\% vs 19 of 218 patients 9.0\%; adjusted risk difference RD, 7.5\%; 95\% CI, 1.5\%-13.6\%;
P
= .01); this difference persisted at 12 months (50 of 232 patients 22.8\% vs 33 of 218 patients 16.3\%; adjusted RD, 7.9\%; 95\% CI, 0.4\%-15.5\%;
P
= .04). There was not a statistically significant difference in severe self-reported hypoglycemia at 6 months between the AD plus previsit and AD-only arms (10 of 232 patients 4.7\% vs 13 of 218 patients 6.5\%; adjusted RD, −2.3\%; 95\% CI, −7.1\% to 2.5\%;
P
= .04).
Conclusions and Relevance
In this randomized clinical trial, AD with previsit activation was a simple and effective strategy for increasing diabetes medication deprescribing in older patients with type 2 diabetes.
Trial Registration
ClinicalTrials.gov Identifier:
NCT04585191
