Intended for healthcare professionals

Practice Practice Pointer

When and how to deintensify type 2 diabetes care

BMJ 2021; 375 doi: (Published 05 November 2021) Cite this as: BMJ 2021;375:e066061

Linked Editorial

Sustainable practice: what can I do?

  1. Carole E Aubert, attending physician and researcher in general internal medicine1,
  2. Iliana C Lega, clinician scientist and assistant professor in the Department of Medicine2,
  3. Olivier Bourron, associate professor of diabetology3,
  4. Alice J Train, patient advisor4,
  5. Jeffrey T Kullgren, research scientist and associate professor in general internal medicine5
  1. 1Department of General Internal Medicine, Inselspital, Bern University Hospital, and Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
  2. 2Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
  3. 3Sorbonne University, Diabetology Department, Pitié-Salpêtrière-Charles Foix Hospital, AP-HP, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
  4. 4Office of Patient Experience (OPE), Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
  5. 5Ann Arbor VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
  1. Correspondence to: C E Aubert carole.aubert{at}

What you need to know

  • Deintensifying type 2 diabetes care can include deprescribing and reducing diabetes-specific assessments that no longer improve quality of life of older adults

  • Based on patient health status and type 2 diabetes control, consider discussing deintensification as part of routine care

  • Consider patient preferences and values to determine goals of care and make shared decisions

Antidiabetic treatment can delay long term complications of type 2 diabetes. However, in some patients—in particular older patients with multimorbidity or those who are frail—the benefits of tight glycaemic control decline and the risks and burdens of antidiabetic treatment increase.123 Observational studies of people with type 2 diabetes who are older or have high clinical complexity have found an association between tight blood glucose control (haemoglobin A1c (HbA1c) of <7% (53 mmol/mol)) and higher risk of falls, severe hypoglycaemia, emergency department visits, hospitalisations, and death.123 Although these risks are well known, there is little advice for clinicians on how and when to discuss deintensifying diabetes care, in contrast to the wealth of guidance on escalating treatment.

In this article, we offer an approach to identifying patients who may benefit from deintensification (that is, loosening blood glucose control targets and other measures that may reduce the burden of diabetes monitoring and care for the patient) and how to reach an individualised and shared management plan with the patient (see fig 1 and box 1). These discussions may also include the patient's informal care givers and relatives, depending on the patient’s wishes and mental capacity.

Fig 1

Approach to care individualisation and deintensification

Box 1

Clinical vignette

A 77 year old woman diagnosed with type 2 diabetes for 15 years, for which she takes metformin and gliclazide. She also takes regular medication (15 tablets each day) for hypertension, atrial fibrillation, heart failure, osteoporosis, and chronic kidney …

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