De-escalating treatment indications for patients who achieve metabolic goals

Ana Cristina Garcia-Ulloa, Salvador Jaime-Casas, Johanna Rosado-Lozoya, NancyH. Serrano-Perez,Diana Hernandez-Juarez,Jose Luis Cardenas-Fragoso, Luis Eduardo Briones-Garcia, Rodolfo Jimenez-Soto, Carlos Garcia-Padilla, Juan Garcia-Lara,Carlos A. Aguilar-Salinas,Sergio Hernandez-Jimenez

DIABETES RESEARCH AND CLINICAL PRACTICE(2024)

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Abstract
Introduction: Robust evidence exists regarding initiation, intensification or modification of treatments. Recommendations to de-escalate therapy are lacking, specifically in diabetes. A successful treatment de-intensification reduces overtreatment, polypharmacy, and risk of adverse effects. Objective: To encompass current recommendations for deprescribing common drugs and create a consensus among health professionals. Methods: We reviewed four databases for deprescribing approaches published between 2010 and 2022. Articles were divided into different groups of drugs (for uric-acid, hypoglycemic, lipid-lowering, and psychotropic drugs). Results: Hypoglycemic agents: strategies were limited to newer agents and insulin regimens for elderly individuals. Reducing insulin was associated with 1.1% reduction of A1c over time. SGLT2i and GLP-1RAs dose reduction depends on adverse events. Lipid-lowering agents: studies show that patients with very low cholesterol have fewer cardiovascular events without associated increased risk. Antihypertensive agents: Younger patients, lower systolic blood pressure, and few comorbidities are ideal characteristics for discontinuation. Uric acid therapy: we found no recommendation for dose de-escalation. Poor treatment adherence is associated with episodes of gout and deforming arthritis in the long term. Conclusion: Deprescribing hypoglycemic, statins, antihypertensives, and urate-lowering agents may be feasible in selected patients, but periodic surveillance is important. More evidence is necessary to support this decision entirely.
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Key words
De-escalating,De-intensification,Diabetes,Dyslipidemia,Metabolic control,Uric acid
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