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Considering Deintensification and Deprescribing with Higher HbA1c Targets in Vulnerable Older Adults with Type 2

Ruriko Koto1, Shiori Yoshida2, Akihiro Nakajima2

  • 1Medical Science Department, Teijin Pharma Limited, 2-1 Kasumigaseki 3-Chome, Chiyoda-Ku, Tokyo, 100-8585, Japan. r.koutou@teijin.co.jp.

Diabetes Therapy : Research, Treatment and Education of Diabetes and Related Disorders
|August 18, 2026
PubMed

Insights

Vulnerable older adults with diabetes face higher severe hypoglycemia risks. Many receive intensive treatment with HbA1c below target, indicating a need for medication review and deprescribing.

Area of Science:

  • Gerontology
  • Endocrinology
  • Clinical Pharmacy

Background:

  • Guidelines recommend individualized hemoglobin (Hb) A1c targets for older adults with diabetes based on vulnerability factors like cognitive impairment and comorbidities.
  • Real-world adherence to these individualized targets and its impact on severe hypoglycemia incidence remain poorly characterized.
  • Vulnerability in older adults with diabetes is a composite of cognitive status, functional ability, and comorbidity burden.

Purpose of the Study:

  • To investigate the association between patient vulnerability and the incidence of severe hypoglycemia in older adults with type 2 diabetes.
  • To evaluate the distribution of HbA1c levels stratified by vulnerability categories and glucose-lowering drug use.
  • To identify risks associated with severe hypoglycemia in vulnerable older diabetic populations.

Main Methods:

  • A Japanese claims database was used to identify adults aged ≥65 years with type 2 diabetes on outpatient glucose-lowering drugs.
  • Patients were categorized into vulnerability groups (Category III: moderate-to-severe dementia or ≥4 comorbidities; Category I+II: others).
  • Severe hypoglycemia incidence was analyzed using negative binomial regression, with HbA1c data summarized from health checkups.

Main Results:

  • Vulnerable patients (Category III) had a significantly higher incidence of severe hypoglycemia (24.96 vs. 4.76 per 1000 person-years) compared to less vulnerable patients (IRR 2.71).
  • Insulin/sulfonylurea/glinide use and prior severe hypoglycemia were identified as major risk factors for hypoglycemia.
  • A substantial proportion of vulnerable patients (48.5%) had HbA1c <6.5%, and 76.9% of those on high-risk medications had HbA1c below the recommended lower limit (7.5%).

Conclusions:

  • Vulnerable older adults with diabetes and high comorbidity burden are at substantially increased risk of severe hypoglycemia.
  • Many vulnerable patients on hypoglycemia-prone medications are treated below recommended HbA1c targets, suggesting suboptimal glycemic control.
  • Medication review, deintensification, and deprescribing are warranted for vulnerable older adults with diabetes to reduce hypoglycemia risk.
Abstract

Keywords:
DeintensificationDeprescribingHbA1cMultimorbidityOlder adultsPolypharmacyReal-world dataSevere hypoglycemiaType 2 diabetes

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