By John Tozzi
American doctors may be giving drugs to a lot of older diabetic patients who are unlikely to benefit and might even be harmed, a new study in JAMA Internal Medicine suggests. Older, sicker patients are treated as aggressively to get their blood sugar under control as healthier patients are, according to an analysis of a nationally representative survey of Americans 65 and older. That's despite what researchers say is greater risk that they'll suffer from dangerously low blood sugar, known as hypoglycemia, and little evidence that they benefit from intense diabetes management.
About 21 million Americans have been diagnosed with diabetes, and another 8 million are undiagnosed, according to the Centers for Disease Control (CDC). The prevailing approach to treating diabetes is to get a measure of patients' average blood sugar over several months, known as hemoglobin A1C, to below 7 percent, says Kasia Lipska, an endocrinologist at the Yale School of Medicine and lead author of the study. But in people with poor health, especially, the benefits of reaching that blood sugar level need to be weighed against the risks of treatment, including hypoglycemia, which can lead to confusion, accidents, falls, comas, or even death. "It’s clearly recognized by guidelines and by some prior research that these strategies are unlikely to result in benefit in people with poor health, and more likely to increase the risk of harm," Lipska says.
Yet treatment of older adults with medication such as insulin or sulfonylurea to control blood sugar didn't vary significantly with patients' health status—meaning sick people at risk of harm from the medications were being treated about as aggressively as healthier patients who were more likely to benefit. The data included 1,288 older Americans with diabetes who were treated between 2001 and 2010.
The research doesn't actually show that these people are being overtreated or that they're experiencing adverse effects, cautions S. Sethu Reddy, chief of adult diabetes at the Joslin Diabetes Center in Boston. The survey that researchers analyzed doesn't have data on patients' outcomes. It also likely includes patients whose blood sugar level is relatively low because they were recently diagnosed with diabetes, not because they were aggressively treated, Reddy says. In general, though, doctors and patients need to weigh the risks and benefits of treatment: "One needs to individualize therapy, and you shouldn’t have the same target for everybody."
Lipska says her findings reflect a broader problem in American medicine: It's much easier for doctors to prescribe treatment to try to get patients to reach a certain measurement than to tailor treatment to the individual. "When the goals are not the same for everyone, it requires a longer discussion, a more complicated risk-benefit analysis," she says. "It’s more complicated but I think it’s better care."