Realigning diabetes regimens in older adults: a 4S Pathway to guide simplification and deprescribing strategies

Treating older people with diabetes is challenging due to multiple medical comorbidities that might interfere with patients' ability to perform self-care. Most diabetes guidelines focus on improving glycaemia through addition of medications, but few address strategies to reduce medication burden for older adults-a concept known as deprescribing. Strategies for deprescribing might include stopping high-risk medications, decreasing the dose, or substituting for less harmful agents. Accordingly, glycaemic management strategies for older adults with type 1 and type 2 diabetes not responding to their current regimen require an understanding of how and when to realign therapy to meet patient's current needs, which represents a major clinical practice gap. With the gap in guidance on how to deprescribe or otherwise adjust therapy in older adults with diabetes in mind, the International Geriatric Diabetes Society, an organisation dedicated to improving care of older individuals with diabetes, convened a Deprescribing Consensus Initiative in May, 2023, to discuss Optimization of diabetes treatment regimens in older adults: the role of de-prescribing, de-intensification and simplification of regimens. The recommendations from this group initiative are discussed and described in this Review.