Optimization of Deprescribing in Older Adults with Diabetes, with Joshua Neumiller, PharmD

Joshua J. Neumiller, PharmD
Credit: Washington State University

The year 2023 marks 20 years since Michael C. Woodward, MBBS, and colleagues first described the concept of deprescribing in older adults in their paper titled “Deprescribing: Achieving Better Health Outcomes for Older People Through Reducing Medications”.

The goal of deprescribing, as described by Woodward and colleagues, was to simplify management and improve quality of life in older patients. In the paper, the team described 4 basic principles of deprescribing:

• Reviewing all current medications
• Identifying medications to be ceased, substituted, or reduced
• Planning a deprescribing regimen with the patient
• Frequently reviewing and supporting the patient

In the 20 years since, knowledge of the concept has grown and found its way into real-world practice but remains shrouded in misconceptions. One of the fields where the concept has gained the most traction is the management of diabetes mellitus. This emphasis on deprescribing in older adults with diabetes was on display at the Association of Diabetes Care and Education Specialists (ADCES) 2023 annual meeting.

Hosted in-person in Houston, TX from August 3-7, 2023, the meeting featured a pair of sessions shining a spotlight on deprescribing. Included in one of these presentations was Joshua Neumiller, PharmD, vice chair and Allen I. White Distinguished Professor

In the College of Pharmacy and Pharmaceutical Sciences at Washington State University, who served as a co-presenter in a session titled “Simplify and Deprescribe: When Less is More for Older Adults with Diabetes,”, which was presented on the final day of the meeting.

The 2021 ADCES Diabetes Care and Education Specialist of the Year and former chairman of the American Diabetes Association’s Professional Practice Committee, Neumiller’s expertise offers a unique perspective on the optimal role of deprescribing as well as shortcomings in the real-world adoption of this practice.

As part of our coverage of ADCES 2023, the HCPLive Endocrinology editorial team sat down with Neumiller to discuss this presentation and the concept of deprescribing in the contemporary management of diabetes. That conversation is the subject of the following Q&A.

HCPLive Endocrinology: We hear the term deprescribing a lot in endocrinology, particularly older patients, but its meaning is often interpreted differently. What does deprescribing mean to you?

Neumiller: I totally agree. I think people talk a lot about deprescribing, but what exactly is meant by that can be confusing and unclear in many instances. The title of our presentation talks about deprescribing, but we are really going to break it down into a variety of different approaches, you can take, really with a goal of individualizing care in older adults with diabetes.

So, some of that can be deprescribing, or actually looking at taking away medications for glucose lowering, or other comorbidities. In other cases, it could be just simply trying to decrease the burden of therapy and trying to simplify the medication regimen. I they're on two different glucose-lowering medications, maybe substitute or see if we can use a combination product or something that can simplify their management strategy.

Sometimes it can be trying to change their treatment goals entirely. For instance, if we have an older adult who is having a lot of issues with hypoglycemia, we may need to change their therapeutic goals that may result in downstream Deprescribing or changing their regimen.

I think the goal of Deprescribing or decreasing the burden of therapy really depends on the situation and what trigger lead to thinking about changing the therapeutic regimen. I think the key things here are thinking about decreasing the burden of therapy for a lot of older adults.

I work in home care, with older individuals, and, often, one of their biggest concerns is just the number of medications and therapies they have to manage on a day-to-day basis. And so many times their goal is just to decrease their polypharmacy, or the number of medications they have to take day to day. For some, it's recurrent hypoglycemia. People have hypoglycemia unawareness and we may have to change our strategy entirely just to keep them safe in their home environment.

To come back to your question: what is the goal of deprescribing? I think it can be different from each person, there might be multiple goals. The approach also can vary from person to person.

HCPLive Endocrinology: How often should care providers be considering deprescribing or having conversations around the topic with older patients?

Neumiller: I think it's a great question. I think it's a bit of a balance, because we often talk about making sure we are encouraging people to practice good adherence to medication, but it is a bit of a balance when talking about deprescribing versus encouraging people to take the medications they need to be healthy and manage their chronic conditions.

So, I think as a health care provider team, we should be always thinking about this. As people age, we should really be reevaluating their individualized goals and priorities. The American Diabetes Association, for example, has their patient-centered care algorithm where they say we should really look at people's goals and reevaluate what we should be doing in terms of their management approach at least once a year. I think that's reasonable.

In my opinion, as people age and get older, I really think it should be reevaluated at each visit. Certainly, looking holistically, are they having issues with maintaining their goals, do they have any new health conditions, or are there concerns that may precipitate a change? Are they having issues with hypoglycemia? This is often a big one in our older adults.

In our presentation, we talked about common triggers for deprescribing or deintensification. Not necessarily talking to the person at each visit about if they think they should deintensify or deprescribe with their regimen, but really looking for key factors as a health care provider that may precipitate that. This could be the individual has frailty or a change in health condition, if they're starting to have issues with cognition or dementia. As people age, often, their kidney function declines and that can affect their medications.

I've talked a lot about hypoglycemia. So, if hypoglycemia is becoming more frequent or unexplained, or they have hypoglycemia unawareness, that is an issue where we really want to interject. If they have potentially inappropriate medication. So, we like to certainly avoid sulfonylureas or bolus insulin in these older adults, because it can put them at increased risk for severe hypoglycemia. People have multiple comorbidities, that may complicate management is another issue.

Another key point is really paying close attention during key life transitions. Their place of care is important. If they're moving to a nursing home or approaching end of life, we really need to reevaluate those goals and priorities and consider simplifying or deprescribing in those individuals.

HCPLive Endocrinology: What is the ideal role of diabetes care and education specialists in deprescribing in older adults with diabetes?

Neumiller: I think certified diabetes care and education specialists play an important role here. The guidelines really focus on intensifying therapy to meet blood glucose goals and guidelines, up until very recently, have not even talked much about how to back off therapy. Within the American Diabetes Association Standards of Care, they talk about the individualization of glycemic targets and therapies, but they do not really talk about how to make those changes, which is where this conversation needs to take place.

I think the diabetes care and education specialist plays an important role here because they are able to spend a lot of time with people with diabetes, their family members, and their caregivers to engage in that shared decision-making process. I think the diabetes care and education specialists often have a unique opportunity to identify some of these key triggers or factors that should precipitate deprescribing or backing off therapy, if you will. I think through these really engaged conversations with the individual, they can be that voice within the multidisciplinary diabetes care team to really convey some of the shared decision-making priorities and preferences of the individual. Often, they can tease out some of these issues with hypoglycemia or issues with managing their medications. We know that transitions of care, which I mentioned is a really important aspect of this, is one of those key points where we like to have people receiving diabetes care and education.

So, diabetes care and education specialists can really be that voice amongst the health care team, to make it known that there are some issues where we may need to back off therapy and make recommendations for more appropriate glycemic targets or changes to the glucose-lowering regimen to keep these individuals safe and independent as possible.

References:

1. Woodward MC. Deprescribing: Achieving better health outcomes for older people through reducing medications. Journal of Pharmacy Practice and Research. 2003;33(4):323-328. doi:10.1002/jppr2003334323
2. Reece SW, Neumiller JJ. Simplify and Deprescribe: When Less is More for Older Adults with Diabetes. Presented at Association of Diabetes Care and Education Specialists (ADCES) 2023 annual meeting. Houston, Texas. August 3-7, 2023.