Realigning diabetes regimens in older adults: a 4S Pathway to guide simplification and deprescribing strategies.
Medha Munshi, Anna R Kahkoska, Joshua J Neumiller, Anastasia-Stefania Alexopoulos, Nancy A Allen, Tali Cukierman-Yaffe, Elbert S Huang, Sei J Lee, Kasia J Lipska, Lisa M McCarthy, Graydon S Meneilly, Naushira Pandya, Richard E Pratley, Leocadio Rodriguez-Ma��as, Alan J Sinclair, Sarah L Sy, Elena Toschi, Ruth S Weinstock
Author Information
Medha Munshi: Joslin Diabetes Center, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
Anna R Kahkoska: Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
Joshua J Neumiller: Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA, USA.
Anastasia-Stefania Alexopoulos: Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
Nancy A Allen: College of Nursing, University of Utah, Salt Lake City, UT, USA.
Tali Cukierman-Yaffe: Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medicine, Herczeg Institute on Aging, Tel-Aviv University, Tel Aviv, Israel.
Elbert S Huang: Department of Medicine, The University of Chicago, Chicago, Il, USA.
Sei J Lee: Division of Geriatrics, University of San Francisco, CA, USA.
Kasia J Lipska: Department of Medicine, Yale School of Medicine, New Haven, CT, USA.
Lisa M McCarthy: Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada; Institute for Better Health, Trillium Health Partners, Mississauga, Canada.
Graydon S Meneilly: Division of Geriatric Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
Naushira Pandya: Department of Geriatrics, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL, USA.
Richard E Pratley: Advent Health Translational Research Institute, Orlando, FL, USA.
Leocadio Rodriguez-Ma��as: Servicio de Geriatria, Hospital Universitario de Getafe, Getafe, Spain.
Alan J Sinclair: Foundation for Diabetes Research in Older People, King's College London, London, UK.
Sarah L Sy: Division of Geriatric Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
Elena Toschi: Joslin Diabetes Center, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
Ruth S Weinstock: Department of Medicine, Upstate Medical University, Syracuse, NY, USA.
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.
