Can anti-diabetic (antidiabetic) medications be discontinued in a diabetic patient later in life and what is diabetes in remission?

Discontinuation of Anti-Diabetic Medications in Older Adults

Yes, anti-diabetic medications can and often should be discontinued or simplified in older diabetic patients, particularly when they are at end-of-life, have declining functional status, or are experiencing hypoglycemia that outweighs the benefits of tight glycemic control. 1

Clinical Scenarios for Medication Discontinuation

End-of-Life and Palliative Care

For patients with type 2 diabetes who are dying, discontinuation of all anti-diabetic medications is a reasonable approach, especially when oral intake has ceased. 1 The primary goals shift from long-term complication prevention to immediate symptom management and quality of life. 1

• Stable patients: Continue previous medications with focus on preventing both hypoglycemia and severe hyperglycemia through blood glucose monitoring. 1

• Patients with organ failure: Preventing hypoglycemia becomes the greatest priority, with glucose targets shifted to the upper end of the desired range; agents causing hypoglycemia should be dose-reduced. 1

• Dying patients with type 2 diabetes: Complete medication discontinuation is appropriate given lack of oral intake. 1 For type 1 diabetes patients, a small amount of basal insulin may be maintained to prevent acute hyperglycemic complications and symptom burden, though no consensus exists. 1

Deintensification to Prevent Hypoglycemia

Overtreatment of diabetes is common in older adults and should be avoided, with deintensification recommended when complex regimens can be simplified while maintaining individualized A1C targets. 1

• Simplification of insulin regimens has been shown to reduce hypoglycemia and disease-related distress without worsening glycemic control. 1

• Sulfonylureas like glipizide should be discontinued first when hypoglycemia occurs, as they directly stimulate insulin secretion regardless of blood glucose levels and provide minimal cardiovascular or renal benefits compared to newer agents. 2

• Metformin should generally be continued as it has the lowest hypoglycemia risk among oral agents and provides cardiovascular benefits. 2

Acute Illness and Hospitalization

Certain medications must be temporarily discontinued during acute illness to prevent metabolic decompensation:

• Metformin should be discontinued during severe COVID-19 illness or hospitalization due to increased lactic acidosis risk, particularly when renal function, tissue oxygenation, or lactate clearance may be compromised. 1, 3

• SGLT-2 inhibitors should be discontinued in patients with severe COVID-19 symptoms to reduce risk of euglycemic or moderate hyperglycemic diabetic ketoacidosis. 1

• These discontinuations are not recommended prophylactically for outpatients without symptoms or evidence of serious illness. 1

What is Diabetes in Remission?

While the provided evidence does not explicitly define "diabetes in remission," the guidelines focus on individualized glycemic targets and treatment simplification rather than complete remission. 1

The concept of remission typically refers to achieving normal glucose levels without anti-diabetic medications, most commonly seen after:

• Significant weight loss through lifestyle intervention or metabolic surgery
• Resolution of secondary causes (e.g., steroid-induced diabetes after corticosteroid withdrawal) 4

However, type 2 diabetes is generally considered a progressive disease, with most patients unable to achieve or sustain near-normoglycemia without medications long-term, and a sizeable proportion eventually requiring insulin therapy. 5

Algorithm for Medication Discontinuation Decisions

Step 1: Categorize Patient Status

• Dying/end-of-life: Discontinue all medications for type 2 diabetes; consider minimal basal insulin only for type 1 diabetes. 1
• Organ failure/declining function: Prioritize hypoglycemia prevention; reduce or stop hypoglycemia-causing agents. 1
• Stable but overtreated: Assess for hypoglycemia risk and regimen complexity. 1

Step 2: Identify High-Risk Medications

• First to discontinue: Sulfonylureas (especially glyburide, which is contraindicated in older adults). 1, 2
• Consider discontinuing: Thiazolidinediones in patients with heart failure or fall/fracture risk. 1
• Generally maintain: Metformin (unless contraindicated by renal function <30 mL/min/1.73m²), GLP-1 receptor agonists for cardiovascular benefits. 1, 2

Step 3: Simplify Insulin Regimens

• Convert complex basal-bolus regimens to basal-only insulin using 70% of total daily dose. 1
• Discontinue prandial insulin if doses are ≤10 units/dose and add non-insulin agents. 1
• Adjust timing from bedtime to morning administration. 1

Step 4: Monitor and Adjust

• Monitor blood glucose closely for 3-4 weeks after any medication changes. 2
• Titrate remaining medications to maintain individualized A1C targets (typically 7.5-8.5% in older adults with multiple comorbidities). 1

Critical Pitfalls to Avoid

• Never discontinue insulin completely in type 1 diabetes patients, even at end-of-life, as this can cause acute hyperglycemic complications and increased symptom burden. 1

• Do not discontinue metformin first when addressing hypoglycemia, as it has the lowest hypoglycemia risk and provides cardiovascular benefits. 2

• Avoid reducing all medications simultaneously, as this makes it difficult to identify the causative agent and can lead to rebound hyperglycemia. 2

• Do not continue metformin in advanced renal insufficiency (eGFR <30 mL/min/1.73m²) due to lactic acidosis risk. 1