Deprescribing in diabetes: A narrative review of pharmacist-led de-escalation of antidiabetic therapy in older and frail adults

The regimen that protects a fifty-year-old from retinopathy two decades hence may, in an eighty-five-year-old with limited life expectancy, deliver nothing but the risk of a fall at three in the morning.Between a quarter and two-fifths of older people with type 2 diabetes are treated below the glycatedhemoglobin thresholds their own guidelines endorse, most often with sulfonylureas or insulin, theclasses least forgiving of missed meals, declining renal function, and blunted counter-regulation.Deprescribing, the deliberate and monitored reduction or withdrawal of medicines whose harms havecome to outweigh their benefits, is the logical corrective, and it remains poorly executed. This reviewexamines why de-escalation fails to happen and argues that the pharmacist is best placed to make ithappen. It traces the pathophysiological basis of hypoglycemia vulnerability in aging, appraises theprincipal instruments: the Bruyèère antihyperglycemic deprescribing algorithm, the American DiabetesAssociation simplification pathway, the Beers and STOPP/START criteria, and STOPPFrail, andsynthesizes the intervention literature on pharmacist-delivered de-escalation. Reported discontinuationrates of forty percent and above, achieved without deterioration in glycemic control, indicate that theintervention works where it is attempted. The persistent obstacles are organizational rather thanpharmacological: prescribing inertia, diffuse accountability at transitions of care, patient interpretationof withdrawal as abandonment, and quality metrics that reward a low glycated hemoglobin withoutregard to the means of attaining it. A five-stage practice model case-finding, appraisal, negotiation,tapering, and surveillance is proposed, with the research priorities most likely to convert a defensibleidea into routine practice.