Prior to QMR

• Review the Quarterly Medication Review Deprescribing Focus – Optimizing Medications & Insulin

During the QMR

• Review A1C and blood glucose targets and assess if within targets recommended by Diabetes Canada for older adults² (see Table 1: Glycemic Targets in Older People with Diabetes on page 2). Assess if there have been any changes in clinical status that may necessitate adjustment of glycemic targets.
• Assess consistency of food intake, particularly if using insulin or sulfonylurea and consult the dietitian as required
• Assess the resident’s current diabetes treatment for opportunities to deprescribe³ (see page 8) and including the resident’s ability to take medications and their goals of treatment
  • Assess for any contraindications and precautions for each class of antihyperglycemic agents
  • Assess renal function; modify dosages of antihyperglycemic agents or asses if medication needs to be stopped
  • Assess if the resident is having any side effects caused by their antihyperglycemic agents and if there are any interventions that can be taken to reduce side effects (e.g. slower titration of medications or dose reduction)
• When considering adding new medications for diabetes treatment and cardiovascular or renal benefits, consider time-to-benefit and the resident’s life expectancy
  • Use a risk stratified approach (e.g., see BMJ tool on page 6) when considering SGLT-2 inhibitors and GLP-1 receptor agonists for residents with type 2 diabetes. Shared decision making is needed so the resident and family are aware of the relative benefit and potential risk of side effects.
• If a new antihyperglycemic agents has been started, monitor effectiveness (e.g. A1C, blood glucose values, symptoms of hyper- or hypoglycemia).  If no or limited benefit seen within 3-6 months^3,4, consider modifying treatment
• If taking insulin, assess for:
  • Is the resident being over basalized?
  • Is the resident using basal and rapid-acting insulin versus NPH and regular insulin?
  • Are lower doses (e.g. 10 units or less per dose) still required?
  • Does the resident have sliding scale (reactive) or correction (supplemental) insulin orders?
  • Can the insulin regimen be simplified?