Diabetes Mellitus Treatment Deintensification
When Well-Controlled Diabetes Mellitus Becomes Overcontrolled
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Diabetes mellitus and its complications, including chronic kidney disease and cardiovascular disease, pose a substantial public health burden. In spite of numerous effective medications for diabetes mellitus, the optimal management of diabetes mellitus remains elusive. Three large randomized controlled trials of intensive glycemic control (HbA1c [Hemoglobin A1c] of 6.4%–6.9% achieved) compared with control arms (HbA1c of 7.0%–8.4%) observed only minor cardiovascular benefits from lower HbA1c targets, and one of those trials found increased all-cause mortality in the intensive treatment arm.1 Although microvascular complications are consistently reduced by better glycemic control, intensive glycemic control has also been consistently associated with increased risk of hypoglycemia.1,2 Reflecting the heterogeneity of patients with diabetes mellitus and the competing risks and benefits of lower glycemic control targets, the American Diabetes Association and the European Association for the Study of Diabetes guidelines for diabetes mellitus treatment recommend individualization of glycemic control goals based on patient preferences, comorbidities, severity of diabetes mellitus–related complications, and life expectancy.3 In spite of the cautious language adopted by the American Diabetes Association and European Association for the Study of Diabetes, many recent studies demonstrate potentially avoidable hypoglycemic events,4 possible overtreatment in vulnerable populations,5–7 and low rates of diabetes mellitus medication deintensification in individuals with low HbA1c or at risk for hypoglycemia.4,8 This growing body of literature has brought attention to the morbidity caused by diabetes mellitus treatment and motivated further investigation into the causes of, consequences of, and strategies to prevent potentially harmful overtreatment.
See Article by McAlister et al
In this issue of Circulation: Cardiovascular Quality and Outcomes, McAlister et al9 report on rates of diabetes mellitus medication deintensification in individuals with recently diagnosed type 2 diabetes mellitus. They used retrospective data from Optum Insight from …