Oral medication for diabetes in elderly patients -
Nevertheless, it has been reported that saxagliptin treatment is associated with an increased risk of hospitalizations for heart failure, also in elderly and very elderly patients [ 18 ]. The cardiovascular CV safety data on the effects of DPP-4 are conflicting since some randomized clinical trials and some real-life studies have reported an increased risk of hospitalizations for heart failure [ 19 ], while a recent meta-analysis shows that DPP-4 inhibitors do not increase the risk of heart failure [ 20 ].
Therefore, the choice of treatment with DPP-4 inhibitors in the elderly patient with type 2 diabetes should take into account of comorbidities, especially heart failure.
Results of cardiovascular outcome trials CVOT have shown that treatment with sodium—glucose cotransporter 2 inhibitors SGLT2i and GLP-1 receptor agonists GLP-1 RA is associated with cardiovascular protection in diabetic patients with established atherosclerotic cardiovascular disease ASCVD and in those with higher ASCVD risk with benefits observed also in patients older than 65 years of age [ 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ].
However, the increased risk of urinary and genital tract infections observed in patients treated with SGLT2i, the possible occurrence of volume depletion, and the development of diabetic ketoacidosis among patients with type 2 diabetes make the use of SGLT2 inhibitors less attractive in acutely ill hospitalized patients with hyperglycemia [ 3 ].
On the other hand, treatment with GLP-1 RA may not be advisable in some frail older patients, particularly those suffering from malnutrition sarcopenia, and cachexia, given that their use is associated with gastrointestinal side effects [ 3 , 9 ].
The inappropriate use of anti-diabetes drugs is frequent, especially in the elderly hospitalized patients. However, although prior studies have shown a high prevalence of potentially inappropriate prescribing for adults living with type 2 diabetes, none of these studies have used an explicit tool specifically designed to identify inappropriate prescribing among people with diabetes, especially in older people [ 31 ].
The aim of this study was to evaluate the appropriateness and the adherence to safety recommendations in the prescriptions of anti-diabetes drugs both at hospital admission and at discharge in a cohort of elderly patients with type 2 diabetes hospitalized in internal medicine and geriatric non-ICU participating in the REPOSI registry study.
The REPOSI is a multicenter and prospective register that started in in order to collect clinical and therapeutic information on patients aged 65 years or older acutely admitted to Italian internal medicine and geriatric non-ICU during four index weeks during each season.
Data collections were continued in , , , and Briefly, patients were eligible for REPOSI if: 1 they were admitted to one of the participating regional internal medicine non-ICU during the four index weeks chosen for recruitment one in February, one in June, one in September, and one in December ; 2 their age was 65 years or older; 3 they gave informed consent.
Each non-ICU had to enroll at least five consecutive eligible patients during each index week, recording data on socio-demographic details, diagnoses, treatment including all drugs taken at hospital admission, and those recommended at discharge.
Then, a final database was created and checked by the Istituto di Ricerche Farmacologiche Mario Negri IRCCS. All patients with and without diabetes were included in the present study analysis.
Participation was voluntary, and all patients provided signed informed consent. REPOSI was approved by the Ethics Committee of the participating centers. The study was conducted according to Good Clinical Practice and the Declaration of Helsinki.
REPOSI register includes older adults admitted to the participating internal medicine and geriatric wards enrolled from up to For this study, data from patients with complete information were evaluated Fig.
Patients with type 1 diabetes were excluded from enrollment from participating centers. All patients with type 2 diabetes were screened in order to determine what type of anti-diabetes drugs they were prescribed, both at hospital admission and discharge.
Hospital admission therapy refers to the treatment taken at home before the admission. Anti-diabetes drugs use at admission and discharge was coded according to the Anatomic Therapeutic Chemical ATC Classification System.
We used the following ATC codes: insulin therapy: A10A, metformin: A10BA, Sulfonylureas: A10BB, Glinides: A10BX02, Pioglitazone: A10BG03, DPP-4 inhibitors: A10BH, GLP-1 RA: A10BJ, SGLT2 inhibitors: A10BK, Acarbose: A10BF Socio-demographic variables, such as age class, marital status, living arrangement, and need for assistance in daily living, were considered, along with laboratory findings in patients with diabetes compared to the ones without it.
The following clinical characteristics were evaluated: cognitive status assessed by the Short-Blessed-Test SBT [ 36 ]; performance in activities of daily living at hospital admission measured by means of the Barthel Index BI [ 37 ]; severity and comorbidity index assessed by the Cumulative-Illness-Rating-Scale CIRS-s and CIRS-c, respectively [ 38 ]; glomerular filtration rate eGFR using the Chronic Kidney Disease Epidemiology Collaboration formula [ 39 ]; length of hospital stay; drug prescriptions at admission and at discharge.
Polypharmacy was defined by the contemporary chronic use of 5 or more drugs [ 40 ]. Prescription appropriateness was assessed according to the American Geriatrics Society Beers Criteria [ 12 ], and the indications according to the European Medicines Agency EMA and Italian Medicines Agency AIFA anti-diabetes drug data sheets.
Briefly, in patients with type 2 diabetes hospitalized for exacerbations of chronic diseases or in the case of acute diseases, it is recommended to prescribe insulin therapy [ 8 , 12 ].
Sulfonylureas and other insulin secretagogues are not recommended in older adults for the increased risk of hypoglycemia [ 8 , 12 ].
Furthermore, sulfonylureas are inappropriate during severe kidney and liver failure and acute illness [ 8 , 12 ]. Pioglitazone is inappropriate during heart failure, several liver impairment and bladder cancer [ 8 , 12 ].
Moreover, it is recommended caution in the use of pioglitazone in case of osteoporosis and history of bone fractures [ 8 , 12 ]. GLP-1 RA therapy is inappropriate in case of acute pancreatitis and end-stage renal disease [ 8 , 12 ].
SGLT2 inhibitors are inappropriate during severe renal failure [ 8 , 12 ]. We divided our sample in two groups according to the presence of type 2 diabetes at admission in hospital. The patients' socio-demographic characteristics were presented using standard descriptive statistics.
We tabulated percentages for discrete variables, mean and standard deviations for continuous variables. Normality for clinical continuous features was checked with Kolmogorov—Smirnov and Anderson—Darling tests. Analogue analyses were performed to assess the appropriateness of each anti-diabetes classes investigated.
Successively, on the sample of diabetic subjects, we studied the relationship between mortality at 3 months after discharge and appropriateness of the antidiabetic therapy according to the combination of the EMA and AIFA data sheets and AGS Beers criteria; we conducted a logistic model regression first univariately and then adjusting Odds Ratios OR for age, sex and comorbidity index.
For this analysis, patients acutely admitted to Italian internal medicine and geriatric non-ICU during the period from up to were evaluated; among them, During the hospitalization 72 patients were diagnosed as having newly diagnosed type 2 diabetes leading to a total number of patients with diagnosis of diabetes at hospital discharge.
As shown in Table 1 , patients with type 2 diabetes were more likely to be men, younger, married, not living alone, and ex-smoker as compared with nondiabetic patients Table 1.
Patients with type 2 diabetes had higher BMI Moreover, a significant higher proportion of patients with type 2 diabetes had comorbidities, such as hypertension, myocardial infarction, peripheral vascular disease, heart failure, liver disease, and chronic kidney disease with significant higher creatinine levels and lower eGFR as compared with nondiabetic patients Table 1 , Table 2.
Furthermore, even if we observed a higher proportion of dementia in nondiabetic individuals than patients with type 2 diabetes, no significant differences were observed regarding overt cognitive impairment between patients with and without diabetes Table 1 , Table 2.
As expected, patients with type 2 diabetes showed significant higher fasting plasma glucose levels than those without diabetes Table 2. Moreover, patients with type 2 diabetes exhibited significantly higher levels of systolic blood pressure, and lower levels of heart rate and total cholesterol than nondiabetic individuals Table 2.
Patients with type 2 diabetes exhibited higher severity index assessed by CIRS-s 1. Furthermore, a significant higher proportion of patients with type 2 diabetes took more of 5 chronic drugs and more of 10 chronic drugs excluded drugs for diabetes than nondiabetic individuals Table 2.
At hospital admission, patients among those with diabetes In particular, Moreover, 2. Surprisingly, at admission only 2. At hospital discharge, we found a significant decrease in the prescription of metformin Furthermore, at hospital discharge, we observed a nominally significant increase in the prescription of GLP-1 RA 0.
We therefore analyzed the prescriptions of glucose-lowering drugs stratified by years of enrollment of patients in the REPOSI register, and we did not find significant differences compared with the overall prevalence, although we observed a trend towards a reduction in the prevalence of the prescriptions of sulfonylureas and repaglinide and an increase in those of DPP-IV inhibitors, and slightly of GLP-RA and SGLT2 inhibitors, in the years — compared to the years — see supplemental materials, Table S1.
Furthermore, we analysed the prescriptions of glucose-lowering drugs stratified by geographic areas of centers participating to REPOSI register that enrolled the patients Northern, Central and Southern Italy.
According to the EMA and AIFA data sheets, among diabetic patients treated with at least one anti-diabetes drug, 99 7. This proportion was reduced at hospital discharge around a half 50 subjects, 3. When we also considered the AGS Beers Criteria, the number of subjects not appropriately treated raised to At hospital admission, At hospital discharge, it was observed a decrease in the inappropriateness of metformin therapy When we considered the appropriateness of anti-diabetes drugs according to the Beers Criteria, the proportion of not appropriate prescriptions of sulfonylureas raised to Finally, we have investigated the impact of appropriateness of anti-diabetes drugs according to the combination of the EMA and AIFA data sheets and AGS Beers criteria on length of hospitalization and mortality at 3 months of subjects with diagnosis of type-2 diabetes.
We observed a similar length of hospital stay between appropriated and not appropriated treated patients with type 2 diabetes Furthermore, we found a higher incidence of mortality at 3 months post-discharge in patients with type 2 diabetes non-appropriately treated as compared to those appropriately treated 8.
Notably, patients with type 2 diabetes not appropriately treated exhibited a 1. This study aimed to evaluate the prescribing appropriateness to safety recommendations of anti-diabetes drugs in hospitalized elderly patients with type 2 diabetes both at admission and at discharge.
Although previous studies have shown a high prevalence of inappropriate prescribing for outpatients with diabetes, none of them evaluated the prescriptive appropriateness of anti-diabetes drugs in hospitalized elderly patients [ 31 ]. We found that at hospital admission According to the AGS Beers Criteria, On the other hand, the ADA Standards of Care recommends avoiding only the prescription of glibenclamide in elderly people, although the sulfonylureas and other insulin secretagogues with caution for their increased risk of hypoglicemia [ 8 ].
At hospital admission, more than a third of patients with diabetes were treated with metformin, and in Treatment with metformin is inappropriate in patients with chronic kidney failure and respiratory insufficiency, and during acute illness due to the increased risk of lactic acidosis [ 8 , 12 ].
We found that hospitalized individuals with diabetes showed a significant impairment of renal function as compared with nondiabetic subjects. Furthermore, we observed that individuals with type 2 diabetes exhibited a significant higher severity index and an increase of comorbidities, such as hypertension, myocardial infarction, peripheral vascular disease, heart failure, liver disease, and chronic kidney disease as compared with patients without diabetes.
Notably, most of these conditions met the criteria of inappropriateness for treatment with metformin, pioglitazone and other anti-diabetes drugs. The present analysis shows that at hospital admission the most prevalent cause of inappropriateness among metformin prescriptions was the low levels of eGFR observed in Therefore, our data underline the critical role of renal function in the evaluation of appropriate antidiabetic treatment in elderly patients hospitalized.
Furthermore, respiratory failure and acute illness were the two more common causes of inappropriateness for metformin treatment in patients both at admission According to this recommendation, we observed that the prescriptions of insulin therapy increased significantly during the hospitalization of patients with diabetes in internal medicine and geriatric non-ICU wards.
Notably, a sliding scale insulin regimen was prescribed to This regimen consisting in administration of short- or rapid-acting insulin 4 to 6 times a day, based on regularly obtained capillary blood glucose levels without concurrent use of basal or long-acting insulin, was not recommended by the Beers Criteria [ 12 ].
However, the most recent Endocrine Society Guidelines suggest both sliding scale and scheduled insulin regimens considering the lower risk of hypoglycemic events, but with a slightly higher daily plasma glucose levels and higher length of hospital stay observed in sliding scale insulin regimen as compared with scheduled insulin therapy [ 40 ].
Additionally, we found that almost half of patients with diabetes were discharged with insulin therapy, whereas there was a significant reduction in the prescription of noninsulin therapies at discharge as compared with the admission.
The Endocrine Society Clinical Practice Guideline suggests that it may be reasonable to begin other noninsulin therapies, such as DPP-4 inhibitors, in stable patients prior to discharge as a part of a coordinated transition plan [ 40 ].
To the best of our knowledge, this is the first study that also evaluated the impact of appropriateness of anti-diabetes drugs in hospitalized elderly patients on mortality post-discharge. Indeed, we found that patients with type 2 diabetes not appropriately treated exhibited a 1. This increased risk remained significant also in adjusted model including age, sex and comorbidity index.
In particular, the variables significantly associated with an increased risk of mortality at 3 months after discharge were age, CIRS and men. These results highlighting the importance of the appropriateness and the adherence to safety recommendations in the prescriptions of anti-diabetes drugs especially in elderly patients with comorbidities who could be exposed to an increased risk of mortality with an inappropriate treatment.
In the present study we also observed a lower prevalence of dementia in patients with diabetes as compared with patients without diabetes, in contrast to previous studies [ 41 ]; this discrepancy could be due to an underestimation of the diagnosis of dementia in hospitalized patients.
Indeed, at admission more patients than those with an established diagnosis of dementia had Overt Cognitive impairment evaluated by Short Blessed Test, with no difference between patients with and without diabetes.
It is conceivable that some concerns about an increased risk of euglycemic ketoacidosis and acute kidney injury especially in the patients with acute illness during the treatment with SGLT2 inhibitors have influenced the therapeutic choice.
However, treatment with GLP-1 RA and DPP-4 inhibitors in hospitalized patients has been associated with similar glycemic control and lower rates of hypoglycemia compared with insulin regimens [ 3 , 16 , 17 ]. Moreover, given that treatment with saxagliptin has been associated with increased risk hospitalization for heart failure [ 18 ], we cannot exclude that DPP-4 inhibitors are prescribed with caution in older diabetic patients with heart failure.
Indeed, a recent meta-analysis has shown that although insulin therapy remains the preferred approach for glycemic management in hospitalized patients, treatment with DPP-4 inhibitors may be appropriate in select patients with type 2 diabetes, including those with well-managed diabetes and those with established noninsulin-requiring diabetes nearing hospital discharge [ 42 ].
A possible explanation for the low use of the new classes of anti-diabetes drugs observed in our analysis may be related to the fact that the elderly patients admitted to the REPOSI registry were enrolled from up to when data of cardiovascular outcome trial were not fully accrued and translated into clinical practice guideline.
Indeed, at hospital discharge, we observed a nominally significant increase in the prescription of GLP-1 RA. Moreover, we observed a trend towards a reduction in the prevalence of the prescriptions of sulfonylureas and repaglinide and an increased use of DPP-4 inhibitors and to a lesser extent of GLP-RA and SGLT2 inhibitors, in the years — compared to the years — Clearly, future analyses on elderly patients admitted to medical and geriatric non-ICU wards after will be needed to determine if there is a greater adherence to recent guidelines on diabetes management and care in the elderly patients.
The present study has some strengths and limitations that merit consideration. A main strength is represented by the multicenter design of the REPOSI register with a large number of internal medicine and geriatric non-ICU wards throughout Italy providing a representative and unselected sample of older in-patients with multiple and severe diseases.
Nevertheless, this study has also some limitations. First, in the frame of the REPOSI register there is no information about diabetes duration and duration of the prescribed therapy. Second, HbA1c, which is the better indicator of long-term glycemic control, is lacking.
Third, in the REPOSI register there is no information about any hypoglycemic events during the hospitalization.
Furthermore, we observed a discrepancy in the number of patients diagnosed with diabetes at discharge that increased with respect as compared with the number of patients with diabetes diagnosis at the time of hospital admission, likely due to newly diagnosed type 2 diabetes diagnosed during hospitalization.
Moreover, in the REPOSI register is not evaluated the economic status. Otherwise, in Italy, this is not an influencing factor concerning the antidiabetic therapy choice. This thanks to the nature of the national health system, which guarantee to all diabetic people to get the best and desired medicaments with a full reimbursement independently by the cost of the therapy.
Because in Italy the health care is entirely tax financed, the present results are not influenced by the level of economic status of the participants at odds with other countries where health care relies on user payment.
Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary.
When you are taking this medicine, it is especially important that your healthcare professional know if you are taking any of the medicines listed below.
The following interactions have been selected on the basis of their potential significance and are not necessarily all-inclusive. Using this medicine with any of the following medicines is usually not recommended, but may be required in some cases. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines.
Using this medicine with any of the following medicines may cause an increased risk of certain side effects, but using both drugs may be the best treatment for you. Certain medicines should not be used at or around the time of eating food or eating certain types of food since interactions may occur.
Using alcohol or tobacco with certain medicines may also cause interactions to occur. The presence of other medical problems may affect the use of this medicine.
Make sure you tell your doctor if you have any other medical problems, especially:. This medicine usually comes with a patient information insert. Read the information carefully and make sure you understand it before taking this medicine.
If you have any questions, ask your doctor. Carefully follow the special meal plan your doctor gave you. This is a very important part of controlling your condition, and is necessary if the medicine is to work properly.
Also, exercise regularly and test for sugar in your blood or urine as directed. Metformin should be taken with meals to help reduce stomach or bowel side effects that may occur during the first few weeks of treatment.
Swallow the tablet or extended-release tablet whole with a full glass of water. Do not crush, break, or chew it. While taking the extended-release tablet, part of the tablet may pass into your stool after your body has absorbed the medicine. This is normal and nothing to worry about.
Measure the oral liquid with a marked measuring spoon, oral syringe, or medicine cup. The average household teaspoon may not hold the right amount of liquid. Use the supplied dosing cup to measure the mixed extended-release oral suspension.
Ask your pharmacist for a dosing cup if you do not have one. Use only the brand of this medicine that your doctor prescribed. Different brands may not work the same way. You may notice improvement in your blood glucose control in 1 to 2 weeks, but the full effect of blood glucose control may take up to 2 to 3 months.
Ask your doctor if you have any questions about this. The dose of this medicine will be different for different patients. Follow your doctor's orders or the directions on the label. The following information includes only the average doses of this medicine.
If your dose is different, do not change it unless your doctor tells you to do so. The amount of medicine that you take depends on the strength of the medicine.
Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are using the medicine. If you miss a dose of this medicine, take it as soon as possible.
For older patients taking a fixed daily dose of insulin who are capable of injecting insulin but not of drawing it into the syringe, a pharmacist or family member may prepare a week's supply of insulin in syringes and leave them in the refrigerator.
Such a plan may allow an older patient to remain living independently at home. Insulin pens, when available and affordable, are an alternative for patients who have difficulty administering insulin using vials and syringes due to vision or motor limitations.
Morning administration reduces the risk of nocturnal hypoglycemia, and fasting hyperglycemia is less of a concern in older patients [ 45 ]. See "Management of hyperglycemia in patients with type 2 diabetes and advanced chronic kidney disease or end-stage kidney disease", section on 'Treatment'.
Insulin therapy is discussed in detail elsewhere. See "General principles of insulin therapy in diabetes mellitus" and "Insulin therapy in type 2 diabetes mellitus".
History of cardiovascular or kidney disease — Sodium-glucose co-transporter 2 SGLT2 inhibitors empagliflozin or canagliflozin or glucagon-like peptide 1 GLP-1 receptor agonists liraglutide or semaglutide are reasonable second agents for patients with established cardiovascular or kidney disease [ 46,47 ].
All of these drugs confer low risk of hypoglycemia on their own or in combination with other drugs that do not usually cause hypoglycemia. GLP-1 receptor agonists should be titrated slowly, with monitoring for gastrointestinal GI side effects, which could precipitate dehydration and acute kidney injury AKI.
We avoid use of SGLT2 inhibitors in patients with frequent bacterial urinary tract infections or genitourinary yeast infections, low bone density and high risk for falls and fractures, foot ulceration, and factors predisposing to diabetic ketoacidosis eg, pancreatic insufficiency, drug or alcohol abuse disorder because of increased risk while using these agents.
See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Cardiovascular effects' and "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Cardiovascular effects'.
Avoidance of hypoglycemia — In older adults at increased risk of hypoglycemia, GLP-1 receptor agonists, SGLT2 inhibitors, and dipeptidyl peptidase 4 DPP-4 inhibitors are options as they are associated with a low hypoglycemia risk.
DPP-4 inhibitors are useful only to improve mild hyperglycemia since they are relatively weak agents and usually lower A1C levels by only 0. However, in frail older adults with late-onset diabetes, particularly patients at high risk of hypoglycemia and impaired awareness of hypoglycemia, a DPP-4 inhibitor can be a useful agent to lower glycemia to the individualized target.
See "Dipeptidyl peptidase 4 DPP-4 inhibitors for the treatment of type 2 diabetes mellitus", section on 'Glycemic efficacy'. Avoidance of weight gain — GLP-1 receptor agonists may be appropriate to use when avoidance of weight gain is a primary consideration and cost is not a major barrier.
SGLT2 inhibitors are also associated with weight loss. However, in the absence of cardiovascular or kidney disease, the risks of SGLT2 inhibitors in older individuals eg, dehydration, falls, fractures may outweigh the benefits.
DPP-4 inhibitors, which are weight neutral, also may be a reasonable option. Cost concerns — If cost is a concern, adding a short- or intermediate-acting sulfonylurea with a relatively lower rate of hypoglycemia, such as glipizide , glimepiride , or gliclazide gliclazide not available in the United States , remains a reasonable alternative.
Choosing a sulfonylurea balances glucose-lowering efficacy, universal local availability, and low cost with risk of hypoglycemia and weight gain.
Short- or intermediate-acting sulfonylureas can also be used cautiously in patients with impaired kidney function when other classes are contraindicated. Generic pioglitazone is also inexpensive.
However, we tend not to use pioglitazone in older adults due to risks of fluid retention, weight gain, heart failure, macular edema, and osteoporotic fracture. See "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus", section on 'Hypoglycemia' and "Thiazolidinediones in the treatment of type 2 diabetes mellitus", section on 'Safety'.
A typical starting dose of a sulfonylurea is as follows see "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus", section on 'Dosing and monitoring' :.
In patients who are using sulfonylureas, the presence and frequency of hypoglycemia should be evaluated at each visit. All blood glucose monitoring BGM or continuous glucose monitoring CGM data that are available should be reviewed and the frequency and details of any recognized episodes of hypoglycemia determined.
See 'Monitoring of glycemia' below and "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus", section on 'Hypoglycemia'. The reported frequency of sulfonylurea-related hypoglycemia in older adults is variable.
In an analysis of adverse event data from a drug surveillance project, oral hypoglycemic agents accounted for 10 percent of hospitalizations for adverse drug events [ 49 ]. Long-acting sulfonylureas eg, glyburide should be avoided in older adults due to higher risk of hypoglycemia, especially in individuals with inconsistent timing or content of their meals or those with cognitive decline that prevents prompt recognition or treatment of hypoglycemic episodes [ 50 ].
Drug-induced hypoglycemia may be a limiting factor for sulfonylurea use in older adults and is most likely to occur in the following circumstances:. These issues may arise when there is a change in overall health status in older adults with diabetes. Dual agent failure — For patients who do not achieve A1C goals with two agents eg, metformin plus sulfonylurea or another agent , we suggest starting or intensifying insulin therapy see "Insulin therapy in type 2 diabetes mellitus", section on 'Designing an insulin regimen'.
In patients on sulfonylureas and metformin who are starting insulin therapy, sulfonylureas are generally tapered and discontinued, while metformin is continued.
Another option is two oral agents and a GLP-1 receptor agonist. It is reasonable to try a GLP-1 agonist before starting insulin in patients who are near glycemic goals, those who prefer to avoid insulin, and those in whom weight loss or avoidance of hypoglycemia is a primary consideration.
A once-weekly GLP-1 agonist formulation is particularly attractive for patients and caregivers. However, this option often increases costs and contributes to the problem of polypharmacy in older adults see 'Polypharmacy and deintensification' below.
The management of persistent hyperglycemia is reviewed in more detail separately. See "Management of persistent hyperglycemia in type 2 diabetes mellitus", section on 'Dual agent failure'.
Polypharmacy and deintensification — Use of multiple drugs is common in older adults. Management of hyperglycemia and its associated risk factors often increases the number of medications even more in the older adult with diabetes.
Side effects may exacerbate comorbidities and impede patients' ability to manage their diabetes. Therefore, the medication list should be kept current and reviewed at each visit [ 1,6 ]. Overtreatment and complicated regimens should be avoided. Complex regimens that may have been required in the past can often be simplified to be consistent with the modified glycemic targets of an older patient [ 53,54 ].
See 'Controlling hyperglycemia' above. It is important to look for any conditions that interfere with A1C measurement eg, anemia, recent infections, kidney failure, erythropoietin therapy, etc.
In these settings or when unexpected or discordant A1C values are encountered, medication adjustments should be based on glucose readings from a glucose meter or continuous glucose monitoring CGM rather than A1C.
See "Measurements of chronic glycemia in diabetes mellitus", section on 'Glycated hemoglobin A1C '. However, infrequent or no BGM may be adequate for older patients with type 2 diabetes who are diet treated or who are treated with oral agents not associated with hypoglycemia.
The effectiveness of BGM in terms of improving glycemic management in patients with type 2 diabetes is less clear than for type 1 diabetes. See "Glucose monitoring in the ambulatory management of nonpregnant adults with diabetes mellitus", section on 'Type 2 diabetes'.
CGM use also should be considered for older patients with impaired awareness of hypoglycemia, those taking other medications that confer higher risk of hypoglycemia eg, sulfonylureas , and those who have difficulty performing BGM through fingerstick checks due to cognitive or physical limitations.
Advances in CGM have made it possible to use the technology in older and even frail patients. Professional CGM devices, applied like a patch on a patient's arm or abdomen depending on the CGM model , measure interstitial glucose levels every 5 to 15 minutes for 10 to 14 days.
These devices provide patterns of glucose excursions that can be the foundation for choosing or adjusting insulin doses in patients on multiple daily insulin regimens. These CGM devices are covered by Medicare in qualifying patients.
See "Glucose monitoring in the ambulatory management of nonpregnant adults with diabetes mellitus", section on 'CGM systems'. Retinopathy, nephropathy, and foot problems are all important complications of diabetes mellitus in older patients.
Monitoring recommendations for older patients with diabetes are similar to those in younger patients table 3. In particular, complications that impair functional capacity eg, retinopathy, foot problems should be identified and treated promptly [ 12 ]. Retinopathy — The prevalence of retinopathy increases progressively with increasing duration of diabetes figure 2.
See "Diabetic retinopathy: Classification and clinical features". Regular eye examinations are extremely important for older patients with diabetes because poor vision can lead to social isolation, an increased risk of accidents, and impaired ability to measure blood glucose and draw up insulin doses.
A complete ophthalmologic examination should be performed by a qualified ophthalmologist or optometrist at the time of diagnosis and at least yearly thereafter. The purpose is to screen not only for diabetic retinopathy, but also for cataracts and glaucoma, which are approximately twice as common in older individuals with diabetes compared with those without diabetes [ 55,56 ].
See "Diabetic retinopathy: Screening". Nephropathy — The availability of effective therapy for diabetic nephropathy with angiotensin-converting enzyme ACE inhibitors, angiotensin receptor blockade agents ARBs , mineralocorticoid receptor antagonists, and sodium-glucose co-transport 2 SGLT2 inhibitors has led to the recommendation that all patients with diabetes be screened for increased urinary albumin excretion annually.
See "Moderately increased albuminuria microalbuminuria in type 1 diabetes mellitus" and "Moderately increased albuminuria microalbuminuria in type 2 diabetes mellitus". However, the prevalence of increased urinary albumin excretion increases in the older population for reasons unrelated to diabetic nephropathy.
For older patients who are already taking an ACE inhibitor or ARB and have progressive decline in glomerular filtration rate GFR or increase in albuminuria, referral to a nephrologist for further evaluation and treatment is warranted. Foot problems — Foot problems are an important cause of morbidity in patients with diabetes, and risk is much higher in older patients.
Both vascular and neurologic disease contribute to foot lesions. See "Management of diabetic neuropathy". In addition to the increasing prevalence of neuropathy with age, more than 30 percent of older patients with diabetes cannot see or reach their feet, and they may therefore be unable to perform routine foot inspections.
We recommend that older patients with diabetes have their feet examined at every visit; this examination should include an assessment of the patient's ability to see and reach his or her feet and inquiry about other family members or friends who could be trained to do routine foot inspections.
Visits to a podiatrist on a regular basis should also be considered if feasible. A detailed neurologic examination and assessment for peripheral artery disease should be performed at least yearly.
It is also important that prophylactic advice on foot care be given to any patient whose feet are at high risk. See "Evaluation of the diabetic foot". In addition, they are at high risk for polypharmacy, functional disabilities, and other common geriatric syndromes that include cognitive impairment, depression, urinary incontinence, mobility impairment, falls, and persistent pain [ 1 ].
See "Comprehensive geriatric assessment". All older adults should undergo screening for mild cognitive impairment or dementia at initial evaluation and, thereafter, annually or as appropriate for the individual patient [ 12 ]. Despite limited treatment options, identification of underlying cognitive impairment is critical for assessing a patient's capacity to self-manage diabetes treatment and care.
In particular, cognitive function and the possibility of depression should be assessed in older patients with diabetes when any of the following are present see "Evaluation of cognitive impairment and dementia" and "Screening for depression in adults" :.
Nursing home patients — Few studies have focused on management of older adults with diabetes residing in nursing homes [ 4 ]. Life expectancy, quality of life, severe functional disabilities, and other coexisting conditions affect goal setting and management plans.
See 'Controlling hyperglycemia' above and 'Avoiding hypoglycemia' above. Treatment regimens should be chosen with a focus on avoidance of hypoglycemia and control of hyperglycemic symptoms [ 17 ]. For patients requiring insulin, metformin combined with once-daily basal insulin is an effective, relatively simple regimen.
If prandial insulin is necessary, it can be administered immediately after a meal to better match the meal size and minimize hypoglycemia. Sliding scale insulin should not be used as a sole means of providing insulin. If a patient is temporarily managed with sliding scale insulin to determine the requisite dose s of insulin therapy, a more physiologic glucose control strategy should be implemented within a few days table 4.
End-of-life care — Management of patients with diabetes at the end of life must be tailored to individual needs and the severity of the illness.
In general, the risks and consequences of hypoglycemia are greater than those of hyperglycemia in patients at the end of life. The goal is to avoid extreme hyperglycemia and dehydration as well as excessive treatment burdens such as multiple insulin injections or intensive monitoring.
For patients with type 2 diabetes who are no longer taking anything by mouth, discontinuation of diabetes medications is reasonable [ 59 ]. This is in contrast to patients with type 1 diabetes, in whom continuing a small amount of basal insulin is required to prevent iatrogenic acute hyperglycemia and ketoacidosis.
See "Palliative care: The last hours and days of life", section on 'Eliminating non-essential medications' and "Deprescribing", section on 'Glucose-lowering medications'. SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.
See "Society guideline links: Diabetes mellitus in adults". Older adults with diabetes are a heterogeneous population that includes persons residing independently in communities, in assisted care facilities, or in nursing homes. They can be fit and healthy, or frail with many comorbidities and functional disabilities.
Therefore, older adults in particular require individualized goals for diabetes management, keeping in mind their limited life expectancy and comorbidities.
See 'Goals' above. Thus, avoidance of hypoglycemia is an important consideration in establishing goals and choosing therapeutic agents in older adults.
See 'Avoiding hypoglycemia' above and "Hypoglycemia in adults with diabetes mellitus", section on 'Strategies to manage hypoglycemia'. See 'Cardiovascular risk reduction' above. The nutrition prescription is tailored for older people with diabetes based upon medical, lifestyle, and personal factors.
Exercise is beneficial to help maintain physical function, reduce cardiac risk, and improve body composition and insulin sensitivity in older patients with diabetes. See 'Lifestyle modification' above. Because of concern for hypoglycemia, some clinicians use insulin only for a short time to ameliorate glucose toxicity.
Once insulin secretion and sensitivity are improved, it may be possible to lower the dose or replace insulin with metformin or another oral hypoglycemic agent with lower risk of hypoglycemia. See 'Choice of initial drug' above. Metformin will likely reduce glycemia safely at any level of hyperglycemia and further may reduce progression of hyperglycemia or the risk of developing diabetes-related complications.
See 'Metformin' above. An alternative option for patients who present with A1C near their medication-treated target and who prefer to avoid medication is a three- to six-month trial of lifestyle modification before initiating metformin.
The approach to choosing alternative therapy in metformin-intolerant patients is similar in older and younger adults. See 'Contraindications to metformin' above and "Initial management of hyperglycemia in adults with type 2 diabetes mellitus", section on 'Contraindications to or intolerance of metformin'.
The therapeutic options for patients who do not reach glycemic goals with lifestyle intervention and metformin are similar in older and younger patients.
All of the medications have advantages and disadvantages table 2. The choice of a second agent should be individualized based upon efficacy, risk of hypoglycemia, the patient's underlying comorbidities, the impact on weight, side effects, and cost figure 1.
See 'Persistent hyperglycemia' above and "Management of persistent hyperglycemia in type 2 diabetes mellitus". Another option is two oral agents and a glucagon-like peptide 1 GLP-1 receptor agonist. See 'Dual agent failure' above. In particular, complications that impair functional capacity eg, retinopathy, foot problems should be identified and treated promptly.
See 'Screening for microvascular complications' above. Cognitive function should be assessed routinely in older adults with diabetes. Unexplained deterioration in glycemia or nonadherence to diabetes care may reflect underlying depression.
See 'Common geriatric syndromes associated with diabetes' above. Why UpToDate? Product Editorial Subscription Options Subscribe Sign in.
Learn how UpToDate can help you. Select the option that best describes you. View Topic. Font Size Small Normal Large. Treatment of type 2 diabetes mellitus in the older patient.
Formulary drug information for this topic. No drug references linked in this topic. Find in topic Formulary Print Share. View in. Language Chinese English. Author: Medha Munshi, MD Section Editors: David M Nathan, MD Kenneth E Schmader, MD Deputy Editors: Katya Rubinow, MD Jane Givens, MD, MSCE Contributor Disclosures.
Oxidative stress and metabolic disorders you diabetfs visiting nature. You are using a browser version with limited support vor CSS. To obtain the best experience, we medicwtion you use a Nutrient timing for muscle growth up i date browser or turn off compatibility mode in Internet Explorer. In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript. Sitagliptin has been suggested as a treatment option for older adults with type 2 diabetes T2D. However, no randomized controlled trial has been performed to evaluate the efficacy and safety of sitagliptin treatment in older Japanese patients with T2D. Diabetes mellitus is a significant health concern for patienys persons in the United States. Evidence elcerly clinical trials mdeication that Water weight reduction plan 8 years eldfrly glycemic Oral medication for diabetes in elderly patients is required before inn in microvascular events can be appreciated. At a minimum, glycemic control should be adequate to prevent symptoms such as polyuria and to avoid hyperglycemic crises. Sulfonylureas lower glucose primarily by stimulating insulin release from pancreatic beta cells. The first-generation sulfonylureas e. Hypoglycemia and weight gain are the major adverse effects of the sulfonylureas. Glipizide and glimepiride are preferred agents in this setting.
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