Diabetes Medications Adjustments for Older Adults Lower Than ADA Guidelines

Type 2 diabetes affects 30% of US adults 65 years or older, many of whom have limited life expectancy, multiple comorbidities, and functional limitations. The American Diabetes Association (ADA) recommends individualizing hemoglobin A_1C (HbA_1C) goals based on health status.¹

A research letter published in JAMA Internal Medicine set out to estimate how often older adults with T2D had their diabetes medications adjusted based on health status and glycemic control.¹

Investigators from the Center for Value-Based Care Research at Cleveland Clinic used electronic health record data from 2019 to 2023, including patients 65 years or older with T2D, 1 or more diabetes medications, and a first HbA_1C measurement in each study year.¹

Patients were classified as having poor, intermediate, or good health based on the presence of terminal conditions or the number of chronic conditions. HbA_1C was considered at goal if it fell between 0% and 1.5% below the ADA's specified targets—below 7.5% for patients with good health, below 8% for those with intermediate health, and below 9% for those with poor health.¹

Deintensification Increased But Remained Uncommon

The study's primary outcomes were regimen intensification and deintensification, defined as an increase or decrease in the number of diabetes drug classes or the dose of noninsulin drugs within 3 months before or after the index HbA_1C measurement.¹

The sample included 89,987 patients with a mean age of 71.6 years; 7.9% had good health status, 61.6% had intermediate health status, and 30.6% had poor health status. Overall, 13.8% of patients had above-goal HbA_1C, 37.8% had at-goal HbA_1C, and 48.4% had below-goal HbA_1C.¹

Among patients with below-goal HbA_1C, deintensification increased from 9.4% in 2019 to 16.9% in 2023 (P < .001), and intensification also rose over the same period, from 4.2% to 7.7% (P < .001), with both changes occurring primarily among patients with intermediate or poor health. Compared with patients at goal, those with below-goal HbA_1C had a similar prevalence of deintensification (16.9% vs 16.3%) and a lower prevalence of intensification (7.7% vs 16.1%) in 2023.¹

By contrast, intensification and deintensification for patients with above-goal HbA_1C changed little over the study period. Intensification remained roughly constant, from 30.7% in 2019 to 32.8% in 2023 (P = .14), and deintensification increased from 14.6% to 20.3% (P < .001). Intensification and deintensification overall were most common among patients with poor health.¹

Findings Signal Gaps for Frail and Otherwise Healthy Patients Alike

The authors noted that among older patients whose HbA_1C was below ADA guideline goals, deintensification doubled from 2019 to 2023, yet by 2023 only 16.9% of these patients had deintensified medication. Intensification for below-goal HbA_1C was less common overall and occurred most often in patients with poor health—a pattern the authors called concerning, since intensive glycemic control in frail or medically complex older adults is associated with increased risks of hypoglycemia and other adverse outcomes.¹

The authors also pointed to a missed opportunity at the other end of the glycemic spectrum. Among patients with above-goal HbA_1C, only 32.8% had intensification, and intensification patterns were similar across health status groups, including among patients with good health. This gap places otherwise healthy older adults at risk for long-term complications such as retinopathy, nephropathy, and cardiovascular disease.¹

The authors cited earlier studies reporting infrequent deintensification among eligible patients and a lack of differential glycemic goals based on patient health status, potentially tied to quality measures that emphasize uniform HbA_1C targets, clinician preference for tighter control, clinician reluctance to deintensify, and patient preference. Sensitivity analyses—excluding insulin users; excluding patients with heart failure, coronary disease, or chronic kidney disease using SGLT-2 inhibitors or GLP-1 receptor agonists; and limiting the sample to sulfonylurea and/or insulin users—produced similar results.¹

Pharmacist Relevance

The study's findings on underused deintensification and intensification align with a broader body of literature on the role of clinical pharmacists in diabetes management. A separate perspective article on pharmacist-led T2D care describes medication therapy management, deprescribing, and patient-centered titration as core pharmacist contributions to individualizing therapy for chronic disease and cites a systematic review finding that collaborative care between pharmacists and physicians was associated with a reduction in HbA_1C and that a majority of pharmacists' medication recommendations were accepted by physicians.²

A related randomized study of hospitalized cardiac patients with diabetes found that patients managed with clinical pharmacist involvement had a statistically significant reduction in HbA_1C compared with those receiving standard care alone.³

Together, these sources point to structured, multidisciplinary medication review as a potential lever for closing the gaps in individualized regimen adjustment identified in the Cleveland Clinic cohort.

REFERENCES

1. Le P, Guo N, Misra-Hebert AD, et al. Intensification and Deintensification of Diabetes Medications Among Older Adults With Type 2 Diabetes. JAMA Intern Med. Published online August 10, 2026. doi:10.1001/jamainternmed.2026.3483

2. Uddin S, Sanchez Machado M, Alshahrouri B, et al. Empowering Pharmacists in Type 2 Diabetes Care: Opportunities for Prevention, Counseling, and Therapeutic Optimization. J Clin Med. 2025;14(11):3822. Published 2025 May 29. doi:10.3390/jcm14113822

3. Mekdad S, Alsayed L, Alkhulaif S. The role of clinical pharmacists in improving diabetic care of hospitalized heart patients. Diabetes Epidemiol Manag. 2025;17:100248. doi:10.1016/j.deman.2024.100248