title: Lack of Evidence to Guide Deprescribing of Antihyperglycemics: A Systematic Review.
abstract: BACKGROUND
  Individualizing glycemic targets to goals of care and time to benefit in persons with type 2 diabetes is good practice, particularly in populations at risk of hypoglycemia and adverse outcomes relating to the use of antihyperglycemics. Guidelines acknowledge the need for relaxed targets in frail older adults, but there is little guidance on how to safely deprescribe (i.e. stop, reduce or substitute) antihyperglycemics.
  
  
  METHODS
  The purpose of this study was to synthesize evidence from all studies evaluating the effects of deprescribing versus continuing antihyperglycemics in older adults with type 2 diabetes. To this end, we searched MEDLINE, EMBASE, and Cochrane Library (July 2015) for controlled studies evaluating the effects of deprescribing antihyperglycemics in adults with type 2 diabetes. All such studies were eligible for inclusion in our study, and two independent reviewers screened titles, abstracts and full-text articles, extracted data, and evaluated risk of bias. Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment and a narrative summary were completed.
  
  
  RESULTS
  We identified two controlled before-and-after studies, both of very low quality. One study found that an educational intervention decreased glyburide use while not compromising glucose control. The other reported that cessation of antihyperglycemics in elderly nursing home patients resulted in a non-significant increase in glycated hemoglobin (HbA1C). No significant change in hypoglycemia rate was found in the only study with this outcome measure.
  
  
  CONCLUSIONS
  There is limited evidence available regarding deprescribing antihyperglycemic medications. Adequately powered, high-quality studies, particularly in the elderly and with clinically important outcomes, are required to support evidence-based decision-making.
  CRD42015017748.
authors.affiliation: Bruyère Research Institute, Ottawa, ON, Canada. cblack@bruyere.org.
authors.forename: Cody D
authors.initials: CD
authors.lastname: Black
authors.affiliation: Bruyère Research Institute, Ottawa, ON, Canada.|School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Wade
authors.initials: W
authors.lastname: Thompson
authors.affiliation: Bruyère Research Institute, Ottawa, ON, Canada.|School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.|Ottawa Hospital Research Institute, Ottawa, ON, Canada.
authors.forename: Vivian
authors.initials: V
authors.lastname: Welch
authors.affiliation: Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.|Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.
authors.forename: Lisa
authors.initials: L
authors.lastname: McCarthy
authors.affiliation: School of Pharmacy, University of Waterloo, Waterloo, ON, Canada.
authors.forename: Carlos
authors.initials: C
authors.lastname: Rojas-Fernandez
authors.affiliation: Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.|The Ottawa Hospital, Ottawa, ON, Canada.
authors.forename: Heather
authors.initials: H
authors.lastname: Lochnan
authors.affiliation: Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Salima
authors.initials: S
authors.lastname: Shamji
authors.affiliation: Dalla Lana Faculty of Public Health, University of Toronto, Toronto, ON, Canada.
authors.forename: Ross
authors.initials: R
authors.lastname: Upshur
authors.affiliation: Bruyère Research Institute, Ottawa, ON, Canada.|School of Pharmacy, University of Waterloo, Waterloo, ON, Canada.|Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Barbara
authors.initials: B
authors.lastname: Farrell
keywords: Antihyperglycemics; Deprescribing; Elderly; Type 2 Diabetes