Assessing Hypoglycemia Risks and Deprescribing in Older T2D Patients

As the global population ages, the management of chronic conditions such as type 2 diabetes (T2D) in older adults has become increasingly complex. A recent study led by Dr. Richard Grant, MPH, a research scientist at the Kaiser Permanente Division of Research in Northern California, emphasizes the critical need for healthcare providers to reconsider their treatment approaches, particularly concerning medication deprescribing in older patients taking insulin and sulfonylureas. These medications, while effective in controlling blood glucose levels, pose a heightened risk of iatrogenic hypoglycemia, a leading preventable complication in this demographic.

The study, published on July 25, 2025, in Medscape Medical News, involved 450 primary care patients with a mean age of 79 years and a mean hemoglobin A1c of 7.5%. It assessed two different strategies for improving diabetes medication deprescribing. The first group of primary care providers received academic detailing, which included evidence-based teaching sessions. The second group received this same academic detailing along with a pre-visit activation strategy that involved an educational handout designed to prepare patients for discussions about their medications during clinical visits. The results showed that patient involvement in these discussions nearly doubled the rate of deprescribing from 9% to 15.8% in six months, highlighting the importance of shared decision-making in diabetes care.

Dr. Pankaj Shah, an endocrinologist at Mayo Clinic, notes, "Iatrogenic hypoglycemia can cause confusion and increase the risk of accidents or even sudden cardiac death." This underscores the serious implications of poorly managed diabetes medications in older adults. Patients who experience severe hypoglycemia face increased risks of hospitalization and adverse health outcomes, making it essential for clinicians to assess the appropriateness of ongoing medications continuously. Shah advocates for a systematic approach to deprescribing, particularly for patients with a history of drug-related complications or limited life expectancy.

Dr. Nestoras Mathioudakis, MHS, an associate professor at Johns Hopkins Medicine, points out the challenges of determining individualized A1c targets for older adults. According to the American Diabetes Association guidelines, an A1c target of less than 8% is recommended for older adults with complex health issues, yet no guidance exists for those with very complex issues or limited life expectancy. As Mathioudakis explains, "For an active, healthy 76-year-old, the benefits of glycemic control may outweigh the risks of hypoglycemia, but this is not a one-size-fits-all scenario."

The hesitance among older adults to change long-standing treatment regimens is another barrier. Many patients are accustomed to strict glycemic control targets, leading to resistance when providers suggest deprescribing or altering medication regimens. As Dr. Scott J. Pilla, MHS, assistant professor at Johns Hopkins Medicine, notes, older patients may struggle with the shift in treatment philosophy.

Innovative approaches, such as employing continuous glucose monitors and alerts in electronic medical records, may facilitate discussions about medication adjustments and enhance patient safety. The study findings advocate for ongoing reassessment of medication needs, particularly as life expectancy declines and the risks of side effects become more pronounced.

In conclusion, the management of T2D in older adults necessitates a paradigm shift away from rigid glycemic control towards a more individualized approach. The involvement of patients in the decision-making process is paramount to achieving safer and more effective diabetes management. Future research and clinical guidelines must continue to address the complexities of deprescribing in this vulnerable population, ensuring that the benefits of treatment outweigh the risks associated with polypharmacy and hypoglycemia. As the healthcare landscape evolves, ongoing education for both providers and patients will be critical in navigating the intricacies of diabetes care among older adults.