Comment on: Willingness to take less medication for type 2 diabetes among older patients

When people with type 2 diabetes age and their health status deteriorates, reevaluation of their treatment is needed. Medication de-intensification is recommended for older patients with a poor health status when they have low levels of hemoglobin A1c while taking medication. The recently published study of Haider et al. investigated the willingness of older people with diabetes to de-intensify their medication.¹ Of particular interest, they examined which patient characteristics were associated with such willingness and whether this aligned with the guideline recommendations. A key finding was that the people who may benefit the most from treatment de-intensification according to the guidelines were less likely to be willing to take less diabetes medication.¹

As Pilla et al. mentioned in an editorial, the study was limited by its reliance on responses to the question “I would be willing to take less medication for my diabetes” that lacks clinical context.² An alternative question has been posed by Crutzen et al. in a study among older people on diabetes and/or cardiovascular drugs.³ This concerns the question from revised Patients Attitudes Towards Deprescribing (rPATD) questionnaire, “If my doctor said it was possible, I would be willing to stop one or more of my regular medicines.”⁴ Crutzen et al. observed that 88% of older patients were willing to stop medication if their doctor said it was possible. This is clearly higher than the 51% willing to take less medication in the study of Haider et al. Although this could indicate that the willingness was higher given the context “that the doctor said it was possible,” an alternative explanation is that the willingness depends on the type of medication. Where the question posed by Haider et al. referred to “less medication for my diabetes,” the medication is not specified in the willingness question of the rPATD.

Differences regarding attitudes toward specific medication were further explored by Crutzen et al.³ In particular, attitudes towards de-intensifying insulin, sulfonylurea, or statins were studied, showing remarkable differences. For example, few of the older people would like their doctor to reduce the dose of their insulin and more than half were reluctant to stop insulin (Table 1). For patients taking sulfonylurea or statins, these percentages were more in favor of de-intensification (Table 1). Furthermore, few people would like to try stopping the insulin or sulfonylurea they were taking to see how they would feel without, whereas more patients would like to try stopping their statin (Table 1). This might be related to experiencing drug-related problems, such as side effects. Very few patients believed they experienced side effects from their insulin or sulfonylurea, but this was clearly different for statins (Table 1). The finding that the willingness of diabetes patients to de-intensify medication depends on the type of medication is not surprising, be beliefs about necessity and concerns also differ for different cardiometabolic drugs.⁵

There are more nuances regarding the question posed that are relevant for patients. De-intensification may include stopping medication as well as reducing treatment intensity. In the study of Haider et al., it is unclear how respondents interpreted “willing to take less medication.” Some might think this implies stopping medication, whereas others may have perceived this as including also dose reductions. Crutzen et al. showed that the majority of the older patients were unsure about wanting to reduce the dose of one or more of their medicines.³

Both Pilla et al. and Haider et al. acknowledge the importance of qualitative studies to provide insight into beliefs and views of people willing or unwilling to de-intensify diabetes medication.^{1, 2} Relevant findings from previous studies include, for example, that some patients have unrealistic expectations of the benefits of diabetes medication and some become confused about changing treatment goals.^{6, 7} Such misconceptions and misunderstandings can be addressed in patient-provider communication. Shared decision-making about medication de-intensification must include a patient-provider conversation about treatment goals and the benefits and risks of continuing a strict treatment regimen.¹ In addition, it should include questions about a patient's medication-specific expectations and experiences, to be taken into account when creating the treatment plan. Furthermore, previous studies identified conditions under which people would be more willing to de-intensify. In particular, close monitoring of clinical outcomes and having the option to restart are relevant for patients with diabetes.^{6, 7} Finally, healthcare providers may need more training to conduct deprescribing consultations and apply deprescribing principles. Recent studies showed that such training can result in more frequent de-intensification of diabetes medication.^{8, 9}

PD wrote the original draft and PS conducted review and editing.

No funding sources.

The authors report no conflicts of interest.