Why Your Diabetes Medication Might Be Too Risky—And How a Pharmacist Can Help

Clinical pharmacists specializing in diabetes can significantly reduce the risk of severe low blood sugar episodes in older adults with type 2 diabetes by reviewing and modifying their medications. A groundbreaking Kaiser Permanente study found that patients who spoke with a pharmacist were nearly twice as likely to switch to safer treatment regimens, and none experienced a dangerous low blood sugar emergency during the six-month study period, compared to 5.3% of patients receiving standard care.

What Is Severe Hypoglycemia and Why Does It Matter?

When most people think about diabetes, they focus on keeping blood sugar levels from getting too high. But there's a dangerous flip side: severe hypoglycemia, or dangerously low blood sugar. "Uncontrolled diabetes is a dangerous disease, and as physicians we primarily focus our attention on making sure people's blood sugar levels are not too high," said Dr. Lisa K. Gilliam, lead author of the study and an endocrinologist with The Permanente Medical Group. "But we also need to look at the flip side of the coin. Hypoglycemia typically gets less attention in the care of type 2 diabetes patients, but it can be dangerous, especially in older adults."

Severe low blood sugar can cause confusion, loss of consciousness, seizures, and even death. The problem is that some commonly prescribed diabetes medications—particularly sulfonylureas and certain types of insulin—can inadvertently trigger these dangerous drops in blood sugar, especially as people age and their bodies change.

How Did Researchers Test This Approach?

The clinical trial, published in JAMA Network Open, included 191 older patients with type 2 diabetes who were at high risk for hypoglycemia or had recently needed emergency care for low blood sugar episodes. The researchers divided patients into two groups: one continued with their usual care, while the other received three consultations with a specialized diabetes pharmacist.

The pharmacist used an evidence-based tool called "Hypoglycemia on a Page" to review each patient's current medications and identify safer alternatives. During these conversations, the pharmacist also educated patients about their hypoglycemia risk and helped set individualized blood sugar targets. The results were striking: at the start of the study, 74% of all patients were taking medications that increased their hypoglycemia risk, yet only about 4% had a prescription for glucagon—an emergency injection used to treat severe low blood sugar.

What Changes Did the Pharmacist Make?

The pharmacist helped patients transition away from high-risk medications by making these specific changes:

• Bolus Insulin Discontinuation: 31 patients (73.8%) stopped using rapid-acting insulin injections, which can cause sudden blood sugar drops.
• Sulfonylurea Discontinuation: 12 patients (28.6%) stopped taking sulfonylurea medications, a class of pills that stimulates the pancreas to release insulin and can trigger hypoglycemia.
• Mixed Insulin Discontinuation: 3 patients (7%) stopped using mixed insulin formulations that combine different insulin types.

Most of these patients were switched to longer-acting insulin formulations, which provide more stable blood sugar control and carry a lower hypoglycemia risk. Some patients discontinued more than one medication type. Additionally, 16 patients (16.7%) who spoke with the pharmacist received a glucagon prescription, compared to only 5 patients (5.3%) in the usual care group.

Why Is This Especially Important for Older Adults?

"Many of the patients whose regimens were changed were older adults, and diabetes is often just one of their health problems," explained Dr. Richard Grant, senior author and a research scientist at Kaiser Permanente. "Also, many older adults have been on the same diabetes treatment regimen for some time. But people change as they get older, and the regimen that was right for them when they were younger might not be the one that is right for them now."

Older adults face unique challenges with diabetes management. Their kidneys and livers may not process medications as efficiently, their awareness of low blood sugar symptoms may decrease, and they're more likely to be taking multiple medications that interact with diabetes drugs. A medication that worked safely at age 55 might become dangerous at age 75.

Did Patients Still Maintain Good Blood Sugar Control?

One concern when changing diabetes medications is whether patients will lose control of their overall blood sugar levels. The study addressed this directly: both groups maintained similar hemoglobin A1C (HbA1C) levels—a measure of average blood sugar over the prior two to three months—keeping them under 8%, which is a standard target for many older adults with diabetes. This means patients got safer medication regimens without sacrificing their long-term blood sugar control.

The study is believed to be the first clinical trial to test a proactive, pharmacist-led intervention specifically designed to reduce diabetes medication risks in older adults. The findings suggest that clinical pharmacists could play a key role in what the International Geriatric Diabetes Society calls the "Deprescribing Consensus Initiative"—a movement to reduce the use of medications that carry unnecessary risks, especially in older populations.

If you're an older adult with type 2 diabetes, especially if you've been on the same medications for years or have experienced low blood sugar episodes, ask your doctor or pharmacist whether a medication review might be appropriate for you. This proactive conversation could be the difference between a safe, stable diabetes management plan and a dangerous one.