When and how to deintensify type 2 diabetes care

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 A_1c (HbA_1c) 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.