This programme will assist the post holder to explore whether de-prescribing interventions have had any impact over the past decade in the last year of life of persons with type 2 diabetes and cardio-metabolic multi-morbidities.
People with type 2 diabetes and established cardiovascular disease have been shown to have an increase in death from cardiovascular causes by 35% and all-cause mortality by 22% when their glycaemia was intensively controlled(1). Less-intensive glycaemic control is appropriate for certain patient groups including those with a history of advanced microvascular and macrovascular complications, long duration of diabetes and severe hypoglycaemic events (2). The rationale for treatment therefore needs to include active withdrawal of treatment to reduce fatigue and drowsiness from medicines which could compromise their self-care.
The focus needs to be on adequate pain relief and the important necessity for avoiding dehydration to enhance their quality of life (3). Terminally ill patients are frequently continued on standard medical care, an effort that may inadvertently worsen end of life issues (4).
While palliative programs have been shown to improve end-of-life care, there is little discussion on rationale prescribing at the end-of-life in such patients and hence the need for interventions to improve he appropriate and rational de-prescribing of diabetes and cardio-metabolic conditions in the last year of life (5, 6.).
Several innovative and policy-supported interventions are needed to better understand prescribing practices in long-term care settings and to curtail the negative, cascading outcomes associated with inappropriate polypharmacy among elderly patients (7-11).
Although these studies have considered the effectiveness of interventions to improve the de-prescribing in the end of life patients it is possible that despite all the interventions over the years to address the problem in people with diabetes, the general trend may not be one of decline. It may have remained the same or worse still, deteriorating.
Therefore, in this research project, this PhD project will seek to address these concerns in 3 work packages:
Work Package 1
A Systematic Review of the Literature on the impact of de-prescribing on Quality of Life and adverse events in people in the last year of life.
The objective of work package will be to isolate the impact of de-prescribing on patient or designated representative reported QOL; satisfaction with care and emergency department visits and hospitalizations.
This systematic review will be of randomized controlled trials and non-randomized prospective studies of older adults (> 65 years or older) and older persons with life-limiting conditions will be included.
Work Package 2
Trends in preventive medication de-prescribing in the last year of life of persons with type 2 diabetes and cardio-metabolic multi-morbidities
The student will evaluate the trends of de-prescribing in people with diabetes nearing their end of life, over the past decade.
Data for this study will be obtained from the UK Clinical Practice Research Datalink (CPRD).
Three main outcome measures will be determined:
- A comparison will be made between the mean number of preventive medications per resident at 1 year, 6 months, 1 month, and 1 week (8 days) before death and on the day of death for the past 10 years.
- A comparison will be made between the preventive medications used 1 year before death versus 1 month before death.
- A comparison will be made between the duration of use of preventive medications in the last year of life.
Work package 3
Perspectives of health professionals towards de-prescribing during end of life: a questionnaire study.
To examine the determinants of de-prescribing among health professionals in the primary care setting focusing on knowledge, practice and attitude.
This will be a questionnaire study comprising conducted online.
In Leicester, we have a diverse academic environment where we can structure training and support the post holder. The training plan will focus on:
Methodology and research training
The Biostatistics research group at Leicester run the MSc in Medical Statistics. The post holder will have to opportunity to join in and get support in research methodology and analysis training.
Gerstein HC, Miller ME, Byington RP, Goff DC Jr, Bigger JT, Buse JB et al. Effects of intensive glucose lowering in Type 2 diabetes. N Engl J Med 2008; 358: 2545–2559.
Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M et al. Management of hyperglycemia in Type 2 diabetes: a patient‐centered approach. Diabetes Care 2012; 35: 1364–1379.
Hutcheson, A. 2001. “Hospice Care in the United States.” Primary Care: Clinics in Office Practice 38 (2): 173-82.
Bailey, F. A., Burgio, K. L., Woodby, L. L. et al. 2005. “Improving Processes of Hospital Care during the Last Hours of Life.” Archives of Internal Medicine 165 (15): 1722-7.
Holmes, H. M. 2009. “Rational Prescribing for Patients with a Reduced Life Expectancy.” Clinical Pharmacology and Therapeutics 85 (1): 103-7.
Currow, D. C., Stevenson, J. P., Abernethy, A. P. et al. 2007. “Prescribing in Palliative Care as Death Approaches.” Journal of the American Geriatrics Society 55 (4): 590-5
Lindsay J, Dooley M, Martin J, Fay M, Kearney A, Barras M (2013) Reducing potentially inappropriate medications in palliative cancer patients: evidence to support deprescribing approaches. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. doi: 10.1007/s00520-013-2098-7
Farrell B, Black C, Thompson W, et al. Deprescribing antihyperglycemic agents in older persons: evidence-based clinical practice guideline. Can Fam Physician. 2017;63:832-843
Black CD, Thompson W, Welch V, et al. Lack of evidence to guide deprescribing of antihyperglycemics: a systematic review. Diabetes Ther. 2017;8:23-31.
Sjöblom P, AndersTengblad, Löfgren UB, et al. Can diabetes medication be reduced in elderly patients? An observational study of diabetes drug withdrawal in nursing home patients with tight glycemic control. Diabetes Res Clin Pract. 2008;82:197-202.
Aspinall SL, Zhao X, Good CB, et al. Intervention to decrease glyburide use in elderly patients with renal insufficiency. Am J Geriatr Pharmacother. 2011;9:58-68