September 2016

Antihyperglycemics Deprescribing
Antihyperglycemics Deprescribing Algorithm
Algorithm August 2018

Does your elderly (>65 years of age) patient with type 2 diabetes meet one or more of the following criteria:
Does your elderly (>65 years of age) patient with type 2 diabetes meet one or more of the following criteria:
Yes • At risk of hypoglycemia (e.g. due to advancing age, tight glycemic • Experiencing, or at risk of, adverse e ects from antihyperglycemic
No
Yes At risk ofmultiple
• control,
control,
hypoglycemia
multiple
(e.g. duedrug
comorbidities,
comorbidities,
to advancing
drug
age,hypoglycemia
interactions,
interactions,
overly intensehistory
hypoglycemia
glycemic
history or
or •• Uncertainty of clinical
• life-expectancy)
t (due to: frailty, dementia or limited No
unawareness, impaired renal function, or on sulfonylurea or insulin)
unawareness, impaired renal function, or on sulfonylurea or insulin)

Continue
• Set individualized A1C and blood glucose (BG) targets (otherwise • Address potential contributors to hypoglycemia Continue�
• healthy with 10+ years life expectancy, A1C < 7% appropriate; Address
• (e.g. not potential contributors to hypoglycemia Antihyperglycemic(s)
considering advancing age, frailty, comorbidities and time-t
eating, drug interactions such as
(e.g. not eating, drug interactionsand
trimethoprim/sulfamethoxazole such as Antihyperglycemic(s)
A1C < 8.5% and BG < 12mmol/L may be acceptable; at end-of life, trimethoprim/sulfamethoxazole and
sulfonylurea, recent cessation of drugs causing
BG < 15mmol/L may be acceptable) (good practice recommendation) sulfonylurea, recent
hyperglycemia – seecessation
reverse) of drugs causing Still at risk? No
hyperglycemia – see reverse) Still at risk? No
Recommend
Recommend Deprescribing
Deprescribing Yes
Yes

Reduce dose(s) or stop agent(s)

Reduce dose(s)
• most likely ortostop
to contribute agent(s)
hypoglycemia (e.g. sulfonylurea, insulin; strong recommendation from systematic review and GRADE approach) or other adverse
• e ects (good practice recommendation)

Switch to an agent
Switch to an
• with lower risk ofagent
hypoglycemia (e.g. switch from glyburide to gliclazide or non-sulfonylurea; change NPH or mixed insulin to detemir or
with lower
• glargine risk of
insulin tohypoglycemia (e.g.hypoglycemia;
reduce nocturnal switch from glyburide to short-acting gliclazide
strong recommendation or non-sulfonylurea;
from systematic change
review and GRADE NPH or mixed insulin to detemir or glargine
approach)
insulin to reduce nocturnal hypoglycemia; strong recommendation from systematic review and GRADE approach)
Reduce doses
Reduce doses
• of renally eliminated antihyperglycemics (e.g. metformin, sitagliptin; good practice recommendation) – See guideline for recommended dosing
• of renally eliminated antihyperglycemics (e.g. metformin, sitagliptin; good practice recommendation) – See guideline for recommended dosing

Monitor daily for 1-2 weeks after each change (TZD – up to 12 weeks): If hypoglycemia continues and/or adverse e ects do not resolve:
Monitor daily for 1-2 weeks after each change (TZD – up to 12 weeks):
• For signs of hyperglycemia (excessive thirst or urination, fatigue)
• Reduce dose further or try another deprescribing strategy
• Reduce dose further or try another deprescribing strategy
•• For signs of hypoglycemia and/or resolution of adverse e ects related to antihyperglycemic(s) If symptomatic hyperglycemia or blood glucose exceeds individual target:
•
Increase frequency of blood glucose monitoring if needed •If symptomatic hyperglycemia
Return to previous or bloodalternate
dose or consider glucose drug
exceeds
withindividual
lower risktarget:
of
Increase frequency of blood glucose monitoring • hypoglycemia
Return to previous dose or consider alternate drug with lower risk of
A1C changes may not be seen for several monthsif needed
A1C changes may not be seen for several months hypoglycemia

© Use freely, with credit to the authors. Not for commercial use. Do not modify or translate without permission.
© Use freely, with credit
This tolicensed
work is the authors.
under aNot for commercial
Creative use. Do not modify or translate without
Commons Attribution-NonCommercial-ShareAlike permission.
4.0 International License.
Contact
This workdeprescribing@bruyere.org
is licensed under a Creativeor visit deprescribing.org
Commons for more information.
Attribution-NonCommercial-ShareAlike 4.0 International License.
Contact deprescribing@bruyere.org or visit deprescribing.org for more information.
Farrell B, Black CD, Thompson W, McCarthy L, Rojas-Fernandez C, Lochnan H, Shamji S, Welch V, Bouchard M, Upshur R.
2016. Evidence-based
Farrell clinicalW,practice
B, Black C, Thompson McCarthyguideline for deprescribing
L, Rojas-Fernandez antihyperglycemics.
C, Lochnan Unpublished
H, et al. Deprescribing manuscript.
antihyperglycemic
agents in older persons. Evidence-based clinical practice guideline. Can Fam Physician 2017;63:832-43 (Eng), e452-65 (Fr).
 Antihyperglycemics Deprescribing Notes August 2018

Antihyperglycemics and Hypoglycemia Risk Engaging patients and caregivers

Does your elderly (>65 years of age) patient with type 2 diabetes meet one or more of the following criteria:
Drug Causes hypoglycemia?
Yes • At risk of hypoglycemia (e.g. due to advancing age, overly •intense
Alpha-glucosidase inhibitor
control, No
multiple comorbidities,
Some
drug interactions, hypoglycemia
older adults• prefer less intensive therapy, especially if burdensome or increases risk of
glycemic
hypoglycemia
history or •
No
unawareness, • Patients and/or caregivers may be more likely to engage in discussion about changing targets or
Dipeptidyl peptidase-4 (DPP-4) impaired
Norenal function, or on sulfonylurea or insulin)
considering deprescribing if they understand the rationale:
inhibitors • Risks of hypoglycemia and other side effects
• Risks of tight glucose control (no benefit and possible harm with A1C < 6%)
Glucagon-like peptide-1 (GLP-1)
agonists
No
• Time to benefit of tight glucose control Continue�
• Addresscertainty
• • Reduced potential contributors
benefit of to hypoglycemia
Antihyperglycemic(s)
about treatment with frailty, dementia or at end-of-life
Insulin Yes (highest risk with • Goals(e.g. notavoid
of care: eating, drug interactions
hyperglycemic symptoms such as dehydration, frequency, falls, fatigue, renal
(thirst,
regular insulin and NPH trimethoprim/sulfamethoxazole
insufficiency) and prevent complications (5-10and years of treatment needed)
insulin) • Manysulfonylurea,
countries agree on less aggressive treatment of diabetes in older persons
recent cessation of drugs causing
Meglitinides Yes (low risk) • Reviewing options for deprescribing,
hyperglycemia – see reverse) as well as the planned
returning to previous doses will help engage patients and caregivers
process for Still at risk?
monitoring and thresholds for
No
Metformin No
Sodium-glucose linked transporter 2
(SGLT2) inhibitors Recommend
No
Deprescribing
Hypoglycemia information for patients and caregiversYes
Sulfonylureas Yes (highest risk with
glyburide and lower risk •
Older frail adults are at higher risk of hypoglycemia
Reduce dose(s) or stop agent(s) with gliclazide) •
There is a greater risk of hypoglycemia with tight control
• •
Symptoms of hypoglycemia include: sweating, tachycardia, tremor BUT older patients may not typically
Thiazolidinediones (TZDs) No
have these
• Cognitive or physical impairments may limit older patient’s ability to respond to hypoglycemia symptoms
Switch to an agent
Drugs affecting glycemic control •
•
Some drugs can mask the symptoms of hypoglycemia (e.g. beta blockers)
Harms of hypoglycemia may be severe and include: impaired cognitive and physical function, falls and
• with lower risk of hypoglycemia (e.g. switch from glyburide to short-acting fractures,gliclazide or non-sulfonylurea;
seizures, emergency change
room visits and NPH or mixed insulin to detemir or glargine
hospitalizations
• Drugsinsulin to to
reported reduce
causenocturnal
hyperglycemiahypoglycemia;
(when thesestrong
drugs recommendation from systematic review and GRADE approach)
stopped, can result in hypoglycemia from antihyperglycemic
Reduce doses
drugs) e.g. quinolones (especially gatifloxacin),
Tapering advice
beta-blockers
• of renally(except carvedilol),
eliminated thiazides, atypical(e.g. metformin, sitagliptin; good practice recommendation) – See guideline for recommended dosing
antihyperglycemics
antipsychotics (especially olanzapine and clozapine),
corticosteroids, calcineurin inhibitors (such as cyclosprine, • Set blood glucose & A1C targets, plus thresholds for returning to previous dose, restarting a drug or
sirolimus, tacrolimus), protease inhibitors maintaining a dose
Monitor daily for 1-2 weeks
• Drugs that interact with antihyperglycemics (e.g. after each change (TZD • – up totapering
Develop 12 weeks):
plan with patient/caregiver (no evidence for one best tapering approach; can stop oral
• Reduce dose further or try another deprescribing strategy
trimethoprim/sulfamethoxazole with sulfonylureas) antihyperglycemics, switch drugs, or lower doses gradually e.g. changes every 1-4 weeks, to the minimum
•
• Drugs reported to cause hypoglycemia (e.g. alcohol, MAOIs, dose available prior to discontinuation, or simply deplete patient’s supply)
• If symptomatic
salicylates, quinolones, quinine, beta-blockers, ACEIs, • Doses may be increased or medication restartedhyperglycemia or blood
any time if blood glucose
glucose exceeds
persists target:
above individual target
Increase frequency of blood glucose monitoring if needed
pentamidine) (12-15 mmol/L) or symptomatic • Return to
hyperglycemia previous
returnsdose or consider alternate drug with lower risk of
A1C changes may not be seen for several months hypoglycemia

© Use freely, with credit to the authors. Not for commercial use. Do not modify or translate without permission.
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Contact deprescribing@bruyere.org or visit deprescribing.org for more information.

Farrell B, Black C, Thompson W, McCarthy L, Rojas-Fernandez C, Lochnan H, et al. Deprescribing antihyperglycemic

agents in older persons. Evidence-based clinical practice guideline. Can Fam Physician 2017;63:832-43 (Eng), e452-65 (Fr).