Diabetes Deprescribing in Older Adults: A Randomized Clinical Trial
Open accessAbstract
Importance: Medication-related hypoglycemia is the leading cause of iatrogenic complications among older adults with type 2 diabetes. Objective: To compare physician academic detailing (AD) with or without patient previsit activation for insulin and/or sulfonylurea deprescribing in older patients with diabetes. Design, Setting, and Participants: This randomized clinical trial was conducted from September 2020 to March 2024 with 6 and 12 months of follow-up in a large integrated health care system in Northern California. Primary care physicians (PCPs) and their patients with type 2 diabetes who were 75 years and older, had hemoglobin A1c of 8.0% or lower, and were treated with insulin and/or sulfonylureas were included. Interventions: Participating PCPs attended at least 1 AD session that provided evidence to support diabetes medication reassessment and potential deprescribing strategies in older patients with type 2 diabetes. Prior to their visit with a participating PCP, trial patients were randomly assigned to receive either a previsit activation deprescribing handout (AD plus previsit arm) or an attention control healthy lifestyle handout (AD-only arm). Main Outcomes and Measures: Primary outcomes (assessed at 6 months) were diabetes medication deprescribing (an aggregate measure) and any patient-reported severe hypoglycemia episodes. Results: A total of 211 PCPs were able to attend at least 1 AD session and treated 450 eligible patients (mean [SD] age, 79.9 [4.0] years; 223 [49.6%] female; mean [SD] concurrent chronic conditions, 6.2 [3.6]; and mean [SD] hemoglobin A1c, 7.5% [1.1%]). At 6 months, there was a statistically significant higher diabetes medication deprescribing rate in the AD plus previsit activation arm compared with the AD-only arm (36 of 232 patients [15.8%] vs 19 of 218 patients [9.0%]; adjusted risk difference [RD], 7.5%; 95% CI, 1.5%-13.6%; P = .01); this difference persisted at 12 months (50 of 232 patients [22.8%] vs 33 of 218 patients [16.3%]; adjusted RD, 7.9%; 95% CI, 0.4%-15.5%; P = .04). There was not a statistically significant difference in severe self-reported hypoglycemia at 6 months between the AD plus previsit and AD-only arms (10 of 232 patients [4.7%] vs 13 of 218 patients [6.5%]; adjusted RD, -2.3%; 95% CI, -7.1% to 2.5%; P = .04). Conclusions and Relevance: In this randomized clinical trial, AD with previsit activation was a simple and effective strategy for increasing diabetes medication deprescribing in older patients with type 2 diabetes. Trial Registration: ClinicalTrials.gov Identifier: NCT04585191.
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Multiple trials have shown that deintensification of diabetes treatment can be achieved successfully and safely.
“Multiple trials have shown that deintensification of diabetes treatment can be achieved successfully and safely (66)(67)(68)(69).”
From 6. Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes-2026. (2026) · cites this paper as [69]
The Results (page not provided) report that this randomized trial achieved diabetes medication deprescribing and found few negative clinical consequences, with no difference between study arms in hyperglycemia-related admissions or HbA1c above 8%. That supports feasibility and a limited safety finding in the older adults studied. This paper reports one trial, however, so it does not itself establish the claim that multiple trials have shown successful and safe deintensification. (LLM, conf=0.88)
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- [53]Fried TR, Ouyang N, Gnjidic D, et al. Communication as a key component of deprescribing: conceptual framework and review of the literature. J Am Geriatr Soc. 2025;73(3):717-727. doi: 10.1111/jgs.19305 [DOI] [PubMed] [Google Scholar] · DOI
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- Authors
- Grant, R. W., Peterson, I., McCloskey, J. M., Lipska, K. J., Nugent, J., Karter, A. J., & Gilliam, L. K.
- Affiliations
- Kaiser Permanente (US)
- Yale University (US)
- Kaiser Permanente South San Francisco Medical Center (US)
- Venue
- JAMA Internal Medicine
- Publisher
- American Medical Association (AMA)
- Published
- 2025-08-01
- Volume
- 185
- Issue
- 8
- Pages
- 926
- ISSN
- 2168-6106 (ISSN-L)
- PMC
- PMC12186576
- OpenAlex
- W4411540720
- Cited by
- 11
- References
- 52
- Citations by year
- 2026: 7 · 2025: 4
- FWCI
- 6.60
- Type
- journal article
- Language
- en
- Open access
- green
- pmc.ncbi.nlm.nih.gov
- Locations
- JAMA Internal Medicine (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (submittedVersion)
- Topics
- Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
- Keywords
- deprescribing, type 2 diabetes, older adults, academic detailing, insulin, sulfonylureas, primary care physicians, severe hypoglycemia, glycemic control, iatrogenic complications, patient handouts, integrated health system
- MeSH terms
- Deprescriptions, Aged, Aged, 80 and over, Diabetes Mellitus, Type 2, Female, Glycated Hemoglobin, Humans, Hypoglycemia, Hypoglycemic Agents, Insulin, Male, Sulfonylurea Compounds
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