Deprescribing
Jen Hand
Sulfonylureas are high risk for older adults due to the possibility of hypoglycemia. A clinical pharmacist intervention achieved a 41% deprescribing rate of sulfonylureas in older adult patients in a managed care setting, according to study results published March 15, 2025, in JAPhA.
Daniel Wadsworth, PharmD, an ambulatory care specialist at Indiana University Health, has seen several older adult patients with diabetes in practice who are affected by hypoglycemia. They reported previous ischemic cardiovascular or fall events resulting in hospitalizations.
“If patients are not checking their blood sugars, the risk of hypoglycemia unawareness on sulfonylureas often outweighs the benefit of tighter glycemic control,” said Wadsworth.
Both the American Diabetes Association and American Geriatrics Society’s Criteria guidelines recommend eliminating or lowering the dosage of sulfonylureas.
However, according to the JAPhA study authors, there seems to be a disconnect in real-world practice.
Study
Using analytics to find potential subjects for deprescribing, researchers looked at pharmacy and medical claims, medical records, laboratory data, and enrollment. To reflect a potentially overtreated population, they included members aged 80 years and older with both a tightly controlled A1C (≤6.5%) within the previous 2 years as well as a sulfonylurea pharmacy claim in the previous 120 days.
The research team, which consisted of clinical pharmacists at a managed care health plan in Florida, identified 89 patients as candidates for discontinuation of sulfonylureas.
Pharmacists reached out directly to the providers managing each patient’s diabetes medications. With brief messaging through EHRs or via phone or fax, pharmacists asked providers to consider deprescribing the sulfonylurea after being given relevant information including rationale for the patient safety initiative, the patient’s most recent A1C value, and current sulfonylurea dose.
The clinical pharmacist deactivated the prescription on file when permission to do a trial discontinuation was given. After pharmacist intervention, the sulfonylurea was discontinued in 41% of the patients. Average A1C postintervention stayed within guideline goals.
The researchers found patients who had a sulfonylurea deprescribed did not differ in age, sex, or comorbid diagnosis from those who continued on it. “However, there were two interesting findings,” said the authors. First, 80% of patients prescribed glipizide extended-release continued to take it. The researchers attributed that to the possible influence of older versions of the Beers Criteria allowing for preference of extended- over immediate-release sulfonylureas. Second and similarly, 72% of patients diagnosed with heart failure remained on the sulfonylurea. The authors concluded that with the shared decision making—while taking into consideration patients’ comorbidities—it was preferable to continue the sulfonylurea in some cases.
Of the study’s patients who had their sulfonylurea discontinued, none experienced a documented hypoglycemic event within a year of the intervention period. Results showed that of the patients who did not have their sulfonylurea discontinued, five experienced a documented hypoglycemic event, three of which were associated with an emergency department visit or hospital admission.
Pharmacist expertise, moving forward
The patients in the cohort did not require immediate replacement of the sulfonylurea. The authors suggested that any future studies including individuals with higher A1Cs would likely require the pharmacist’s expertise with recommendations for an appropriate alternative while also considering comorbidities, cost, and patient preferences.
“The clinical pharmacist can play a role in monitoring changes in blood sugars, improving access to alternative agents, and assessing whether the patient truly needs tight glycemic control,” said Wadsworth.
The study authors concluded that their systematic approach could enhance collaborative care by streamlining decision making, while their model can be “readily adopted to other potentially inappropriate medications and high-risk populations.” ■