• Scott J Pilla, Kayla A Meza, Nancy L Schoenborn, Cynthia M Boyd, Nisa M Maruthur, and Geetanjali Chander.
• Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. spilla1@jhmi.edu.
• J Gen Intern Med. 2023 Mar 1; 38 (4): 100810151008-1015.

BackgroundWhile many older adults with type 2 diabetes have tight glycemic control beyond guideline-recommended targets, deintensifying (stopping or dose-reducing) diabetes medications rarely occurs.ObjectiveTo explore the perspectives of older adults with type 2 diabetes around deintensifying diabetes medications.DesignThis qualitative study used individual semi-structured interviews, which included three clinical scenarios where deintensification may be indicated.ParticipantsTwenty-four adults aged ≥65 years with medication-treated type 2 diabetes and hemoglobin A1c <7.5% were included (to thematic saturation) using a maximal variation sampling strategy for diabetes treatment and physician specialty.ApproachInterviews were independently coded by two investigators and analyzed using a grounded theory approach. We identified major themes and subthemes and coded responses to the clinical scenarios as positive (in favor of deintensification), negative, or ambiguous.Key ResultsParticipants' mean age was 74 years, half were women, and 58% used a sulfonylurea or insulin. The first of four major themes was fear of losing control of diabetes, which participants weighed against the benefits of taking less medication (Theme 2). Few participants viewed glycemic control below target as a reason for deintensification and a majority would restart the medication if their home glucose increased. Some participants were anchored to their current diabetes treatment (Theme 3) driven by unrealistic views of medication benefits. A trusting patient-provider relationship (Theme 4) was a positive influence. In clinical scenarios, 8%, 4%, and 75% of participants viewed deintensification positively in the setting of poor health, limited life expectancy, and high hypoglycemia risk, respectively.ConclusionsOptimizing deintensification requires patient education that describes both individualized glycemic targets and how they will change over the lifespan. Deintensification is an opportunity for shared decision-making, but providers must understand patients' beliefs about their medications and address misconceptions. Hypoglycemia prevention may be a helpful framing for discussing deintensification.© 2022. The Author(s), under exclusive licence to Society of General Internal Medicine.

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