Abstract
Objectives
Contemporary guidelines suggest relaxed glycemic targets in populations with type
2 diabetes mellitus (T2DM) at risk of hypoglycemia, including people with multimorbidity,
limited life expectancy or frailty. However, overtreatment remains commonplace. To
inform safe deprescribing, a previous systematic review investigated the benefits
and harms of deprescribing antihyperglycemics, but identified only limited, very low-quality
evidence. We sought to update that review and identify and describe newly published
literature on the effects of deprescribing antihyperglycemics in older adults with
T2DM.
Methods
We searched MEDLINE, EMBASE and the Cochrane Library (July 2015 to January 2021) for
controlled studies published in English addressing the effects of deprescribing vs
continuing antihyperglycemics in adults with T2DM. Two independent reviewers performed
title, abstract and full-text screening, data extraction and risk-of-bias assessment.
Cochrane’s risk-of-bias tools, RoB 2 and ROBINS-I, were used. The findings were summarized
narratively. GRADE (Grading of Recommendations, Assessment, Development and Evaluations)
was used to evaluate the evidence.
Results
We identified 4 additional investigations—2 randomized controlled trials and 2 retrospective
cohort studies. After deprescribing, 3 studies reported no clinically significant
changes in glucose management and 2 studies reported reductions in adverse events
(e.g. hypoglycemia, all-cause mortality and nonspine fractures). However, based on
GRADE assessment, we found very low certainty of the evidence due to concerns of risk
of bias (e.g. unmeasured confounding), imprecision, and indirectness.
Conclusions
Deprescribing antihyperglycemic medications in older adults with T2DM is likely feasible
and safe, and benefits may outweigh the harms. However, the evidence indicates very
low certainty. Additional deprescribing studies are needed with rigorous methodologies
and reporting.
Résumé
Objectifs
Les lignes directrices contemporaines font état de valeurs cibles assouplies de la
glycémie pour les populations atteintes du diabète sucré de type 2 (DST2) qui sont
exposées au risque d’hypoglycémie, notamment les personnes qui présentent une multimorbidité,
une espérance de vie limitée ou une fragilité, mais le surtraitement demeure courant.
Pour orienter les cliniciens sur la déprescription sécuritaire, une revue systématique
antérieure a porté sur les avantages et les inconvénients de la déprescription des
antihyperglycémiants, mais a seulement permis de relever des données probantes limitées
de très faible qualité. Nous avons cherché à actualiser cette revue, et à déterminer
et à décrire la littérature récemment publiée sur les effets de la déprescription
des antihyperglycémiants chez les personnes âgées atteintes du DST2.
Méthodes
Nous avons effectué des recherches dans MEDLINE, Embase et Cochrane Library (de juillet
2015 à janvier 2021) pour trouver des études comparatives publiées en anglais qui
portaient sur les effets de la déprescription vs la poursuite des antihyperglycémiants chez les adultes atteints du DST2. Deux examinateurs
indépendants ont effectué le filtrage des titres, des résumés et des textes intégraux,
l’extraction des données et l’évaluation du risque de biais. Les outils d’évaluation
du risque de biais de Cochrane, RoB2 et ROBINS-I, ont été utilisés. Les résultats
ont fait l’objet d’une synthèse narrative. Le GRADE (Grading of Recommendations, Assessment,
Development and Evaluations) a été utilisé pour évaluer les données probantes.
Résultats
Nous avons trouvé 4 autres études—2 essais comparatifs à répartition aléatoire et
2 études de cohorte rétrospectives. Après la déprescription, 3 études ne faisaient
état d’aucun changement cliniquement significatif de la régulation de la glycémie
et 2 études faisaient état d’une réduction des événements indésirables (p. ex. l’hypoglycémie,
la mortalité toutes causes confondues et les fractures non vertébrales). Toutefois,
selon l’évaluation GRADE, nous avons observé des données probantes de très faible
certitude en raison des préoccupations sur le risque de biais (p. ex. les facteurs
de confusion non mesurés), l’imprécision et le caractère indirect).
Conclusions
La déprescription des médicaments antihyperglycémiques chez les personnes âgées atteintes
du DST2 est probablement faisable et sécuritaire, et les avantages peuvent l’emporter
sur les inconvénients. Toutefois, les données probantes montrent une très faible certitude.
D’autres études qui portent sur la déprescription et qui sont basées sur des méthodologies
et des comptes rendus rigoureux sont nécessaires.
Keywords
Mots clés
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Article info
Publication history
Published online: February 02, 2022
Accepted:
January 27,
2022
Received in revised form:
December 9,
2021
Received:
July 19,
2021
Identification
Copyright
© 2022 Canadian Diabetes Association.
