Diabetes Deprescribing in Older Adults: A Randomized Clinical Trial.

Grant RW, et al. · 2025

PubMed 40549370 ↗DOI: 10.1001/jamainternmed.2025.2015JAMA internal medicine

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💊 Lavora su: Terapia · lente Traiettoria · il corpo nel tempo

tocca anche 🧠 Mente & vita

RCT (prova forte)

La domanda

Negli anziani (≥75 anni) con diabete tipo 2 trattati con insulina e/o sulfaniluree e HbA1c ≤8%, affiancare l'attivazione del paziente prima della visita alla formazione del medico aumenta la deprescrizione dei farmaci a rischio ipoglicemia?

Cosa hanno trovato

RCT in un grande sistema sanitario integrato (California del Nord), 211 medici di base e 450 pazienti (età media 79,9 anni; 49,6% femmine; in media 6,2 patologie croniche; HbA1c media 7,5%). Confronto tra 'academic detailing del medico + foglio di attivazione pre-visita al paziente' vs 'solo academic detailing'. Deprescrizione a 6 mesi: 15,8% (36/232) vs 9,0% (19/218); differenza di rischio aggiustata +7,5% (IC 95% 1,5%-13,6%; P=0,01); persistente a 12 mesi 22,8% vs 16,3%, RD aggiustata +7,9% (IC 95% 0,4%-15,5%; P=0,04). Ipoglicemia grave auto-riferita a 6 mesi: 4,7% (10/232) vs 6,5% (13/218); RD aggiustata -2,3% (IC 95% da -7,1% a +2,5%), differenza non significativa.

Cosa significa per te

Riguarda l'anziano con tipo 2. Un intervento semplice ed economico (un foglio informativo consegnato al paziente prima della visita) aumenta la probabilità di ridurre i farmaci che possono causare ipoglicemia. Lo studio non ha però dimostrato una riduzione degli episodi ipoglicemici gravi (non era dimensionato per quell'esito). Ogni riduzione o sospensione di terapia va concordata con il curante.

Abstract (in lingua originale)

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 A1c 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 A1c, 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.

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Come leggerlo: è uno studio scientifico peer-reviewed. Le evidenze aiutano a capire i trend, ma un singolo studio non è una prescrizione: parlane col tuo diabetologo prima di cambiare dieta o terapia.