• Scott J Pilla, Rabia Jalalzai, Olive Tang, Nancy L Schoenborn, Cynthia M Boyd, Michael P Bancks, Nestoras N Mathioudakis, and Nisa M Maruthur.
• Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. spilla1@jhmi.edu.
• J Gen Intern Med. 2024 May 1; 39 (6): 9921001992-1001.

BackgroundGuidelines recommend deintensifying hypoglycemia-causing medications for older adults with diabetes whose hemoglobin A1c is below their individualized target, but this rarely occurs in practice.ObjectiveTo understand physicians' decision-making around deintensifying diabetes treatment.DesignNational physician survey.ParticipantsUS physicians in general medicine, geriatrics, or endocrinology providing outpatient diabetes care.Main MeasuresPhysicians rated the importance of deintensifying diabetes medications for older adults with type 2 diabetes, and of switching medication classes, on 5-point Likert scales. They reported the frequency of these actions for their patients, and listed important barriers and facilitators. We evaluated the independent association between physicians' professional and practice characteristics and the importance of deintensifying and switching diabetes medications using multivariable ordered logistic regression models.Key ResultsThere were 445 eligible respondents (response rate 37.5%). The majority of physicians viewed deintensifying (80%) and switching (92%) diabetes medications as important or very important to the care of older adults. Despite this, one-third of physicians reported deintensifying diabetes medications rarely or never. While most physicians recognized multiple reasons to deintensify, two-thirds of physicians reported barriers of short-term hyperglycemia and patient reluctance to change medications or allow higher glucose levels. In multivariable models, geriatricians rated deintensification as more important compared to other specialties (p=0.027), and endocrinologists rated switching as more important compared to other specialties (p<0.006). Physicians with fewer years in practice rated higher importance of deintensification (p<0.001) and switching (p=0.003).ConclusionsWhile most US physicians viewed deintensifying and switching diabetes medications as important for the care of older adults, they deintensified infrequently. Physicians had ambivalence about the relative benefits and harms of deintensification and viewed it as a potential source of conflict with their patients. These factors likely contribute to clinical inertia, and studies focused on improving shared decision-making around deintensifying diabetes medications are needed.© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.

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