Research from Cleveland Clinic shows many older adults with diabetes are not receiving treatment adjustments aligned with individualised HbA1c targets, risking both over- and under-treatment effects.
In older adults with type 2 diabetes, most people whose HbA1c levels were outside recommended targets did not have their treatment adjusted in line with guideline goals, according to a Cleveland Clinic-led study published in JAMA Internal Medicine and reported by MedPage Today. The analysis of electronic health record data from 2019 to 2023 suggests clinicians often missed chances both to ease treatment when glucose control was too tight and to step up therapy when it was too loose.
The researchers reviewed almost 90,000 patients aged 65 and over and found that 48.4% had HbA1c levels below goal, 37.8% were at goal and 13.8% were above goal. Among those below target, only 16.9% had diabetes treatment deintensified, while 32.8% of patients above target had therapy intensified. Phuc Le, the study’s lead author, told MedPage Today that the findings pointed to “opportunities to improve treatment alignment at both ends of the glycaemic spectrum”.
The study defined targets according to health status, in keeping with long-standing guidance that older adults should not be treated to a one-size-fits-all HbA1c level. Healthier patients were judged against a lower target, while those with several chronic conditions or poor health had higher thresholds intended to reduce the risk of hypoglycaemia and other harms. That approach is consistent with guidance from the American Geriatrics Society, the American Diabetes Association and NICE, all of which recommend individualising glucose goals in older and frailer adults.
The researchers said the pattern was particularly concerning when treatment was intensified in patients already below goal, especially among those in poor health. That group is more vulnerable to adverse effects from overly aggressive glucose lowering, including hypoglycaemia, falls and other complications. At the same time, the study found that some healthier older adults with HbA1c above goal were not escalated, which the authors described as a missed chance to reduce the risk of longer-term diabetes complications.
Le said deintensification should not be mistaken for undertreatment, but rather for appropriate care when medication burden or hypoglycaemia risk outweighs benefit. The study could not determine why individual clinicians chose to change, or not change, therapy. Still, the authors argued the results show a need to make personalised HbA1c goals a more explicit part of routine decision-making and to make better use of safer glucose-lowering options in older patients.
Disclaimer: This content is for informational purposes only and is not intended to be a substitute for professional medical judgment, advice, diagnosis, or treatment.
