Tight glucose control reduces microvascular complications at the cost of an increased risk of hypoglycemia. Guidelines recommend conservative management for older adults with diabetes, particularly in the setting of comorbidities. We examined the proportion of older adults with diabetes treated with tight glucose control and the factors associated with this practice.
Cross-sectional analysis of 42,669 adults ≥75 years of age with type 2 diabetes from 151 US outpatient sites in the Diabetes Collaborative Registry.
Patients were categorized based on HbA1c and glucose-lowering medications: poor control (HbA1c >9%), moderate control (HbA1c >8–9%), conservative control (HbA1c 7–8%), tight control (HbA1c <7%) with low-risk agents (low risk for hypoglycemia), tight control with high-risk agents, and diet control (HbA1c <7% on no glucose-lowering medications). We used hierarchical logistic regression to examine patient and site factors associated with tight control/high-risk agents vs. conservative control or tight control/low-risk agents.
Among 30,696 patients without diet controlled diabetes, 5,596 (18%) had moderate or poor control, 9,227 (30%) had conservative control, 7,893 (26%) had tight control on low-risk agents, and 7,980 (26%) had tight control on high-risk agents. Older age, male sex, heart failure, chronic kidney disease, and coronary artery disease were each independently associated with a greater odds of tight control with high-risk agents. There were no differences among practice specialties (endocrinology, primary care, cardiology) in how aggressively the patients were managed.
We found that a quarter of US older adults with type 2 diabetes are tightly controlled with glucose-lowering medications that have a high risk of hypoglycemia. These results suggest potential overtreatment of a substantial proportion of patients and should encourage further efforts to translate guidelines to daily practice.