New study provides first published examples of medication deprescribing protocols for type 2 diabetes

A qualitative case series research study published in Clinical Diabetes provides the first published examples of protocols to help guide clinical decision making on when and how to deprescribe medications following successful lifestyle medicine interventions to treat patients with type 2 diabetes.

The results of the case series are important because intensive therapeutic lifestyle change can lead to substantial and rapid decreases in blood sugar that result in hypoglycemia if prescription medications go unadjusted. However, limited relevant literature often leaves clinicians without adequate resources to help them deprescribe safely and effectively.

"The research team was able to document a variety of approaches that exist to successfully deprescribe glucose-lowering medications in a safe and effective way," said Michael Bradley, PharmD, MPH, CDCES, CPH, who was first author on the paper. "As the practice of evidence-based lifestyle medicine to treat and attain remission of type 2 diabetes grows, these deprescribing protocols will become increasingly valuable to clinicians who are able to reduce the need for prescription medications and to their patients."

Lifestyle medicine interventions are an emerging solution to the crisis of type 2 diabetes, which is the seventh leading cause of death in the United States. The Centers for Disease Control and Prevention (CDC) estimates that more than 34.2 million Americans have type 2 diabetes with an estimated cost in 2017 of $327 billion.

The American Diabetes Association and American Association of Clinical Endocrinology recommend lifestyle optimization as part of medical care for type 2 diabetes, and an expert consensus statement published in May reported multi-organizational agreement that dietary changes alone are capable of achieving remission in people type 2 diabetes.

For the study published in Clinical Diabetes, researchers conducted in-depth interviews of lifestyle medicine providers experienced in treating type 2 diabetes with the clinical goal of achieving remission. Most interviewees did not use a published protocol or algorithm for medication deprescribing, but rather shared their own decision-making process and protocols.

Among the key findings was that lifestyle medicine clinicians practice de-escalation of glucose-lowering medications when patients with type 2 diabetes develop a reduced need for pharmacotherapy, and that the clinicians often work in multidisciplinary teams of allied health professionals when deprescribing medications.

Medications that are often deprescribed first are those known to cause hypoglycemia as an adverse effect—often sulfonylureas or insulin—with a goal for patients to achieve normoglycemia, the study reported.

"While guidelines do not yet exist for medication deprescribing in a lifestyle medicine context, these example protocols may be helpful for other clinicians seeking input on current best practices in deprescribing," said Micaela Karlsen, Ph.D., ACLM Senior Director of Research.

The authors called for the establishment of clinical practice guidelines and point-of-care tools for medication deprescribing, as well as clinician and patient education materials. The authors also recommended more research on health outcomes resulting from intensive therapeutic lifestyle interventions and comparisons of medication deprescribing practices.