番茄社区

Older patients with diabetes can pose a challenge for providers to manage, as their unique goals and risks must be carefully balanced against each other.

"Individualization and simplification of the treatment regimen is important when caring for older adults with diabetes because of the many competing priorities these patients may face when taking numerous medications to treat multiple chronic conditions associated with aging," Peggy Odegard, PharmD, CDE, of the University of Washington School of Pharmacy in Seattle, told 番茄社区.

In addition to carefully tailoring the treatment regimen to the patient's specific needs, ongoing attention should also be placed on the patient's capability to self-manage their treatment, as well as their need for treatment adherence support, Odegard added.

This sentiment was echoed by John Morley, MD, of Saint Louis University Hospital, who recommended that all elderly patients with diabetes should be screened for cognitive function due to the heightened associated risk with diabetes. Dementia can also interfere with the patient's ability to follow physician instructions and adherence to treatment regimens, he told 番茄社区.

recommend screening for early detection of mild cognitive impairment as well as depression in older patients with diabetes, starting at age 65. The guidelines state that "when clinicians are managing patients with cognitive dysfunction, it is critical to simplify drug regimens and to involve caregivers in all aspects of care."

Managing cardiovascular risk factors must also be a top priority, Odegard said, highlighting the increased risk that poorly controlled diabetes poses to both cardiovascular and brain health in this older patient population.

Other risks clinicians should pay close attention to include both bone health and muscle loss. "[People with diabetes] have accelerated muscle loss leading to sarcopenia ... [and] that loss of muscle function is the major reason for hospitalization and disability in older diabetics," Morley noted.

Target Range

When it comes to glucose control, target ranges for older patients aren't quite as cut-and-dried as those for younger patients.

"Glycemic targets should be individualized for older adults, based on factors such as health complexity, presence of cognitive impairment, and risk for hypoglycemia or other side effects from diabetes treatments," Odegard said.

"In general, according to the ADA Standards of Practice, a suggested glycemic target for older adults who are otherwise healthy with few chronic illnesses, good cognitive function and functional status is an A1c <7.5%, while a less stringent target such as <8-8.5% would be safer for those with poorer health or reduced functional or cognitive status," she added.

Morley agreed, stating that an upper limit around 8 is safer for frail patients or individuals residing in a nursing home. However, he said it's important to also bear in mind that comorbidities, such as diabetic retinopathy, could show progression with an A1c above 7.

When setting treatment goals, the ADA states that although life expectancies of older patients with diabetes are "highly variable," they are often longer than many providers may realize. The ADA recommends that "providers caring for older adults with diabetes must take this heterogeneity into consideration when setting and prioritizing treatment goals."

Safe Treatment Regimens

Special consideration must be given to what treatment regimens are safest – whether they include oral or injectable therapy.

Specifically, metformin and DPP-4 inhibitors, such as sitagliptin (Januvia) and linagliptin (Tradjenta), are some of the top choices when it comes to treating elderly patients, Morley said.

Odegard agreed, adding that "for older adults with type 2 diabetes, metformin is effective and safe with appropriate titration of the dose to reduce risk of gastrointestinal intolerance and with attention to renal and hepatic function. As with the treatment of type 2 diabetes in the general adult population, metformin is the preferred starting option for treatment of type 2 diabetes in older adults given its effectiveness, overall safety and low cost."

Although insulin can also be a very effective treatment, safety is a concern in regards to hypoglycemia risk and possible dosing inaccuracies, which may stem from vision changes and dexterity challenges that come with older age.

"If insulin is indicated, patient education with return demonstration of dosing is important to assure competence and accuracy," Odegard said. "Given the increased risks of hypoglycemia in older adults, attention to minimize these risks should be given if insulin is used."

Providers may also be wary of prescribing thiazolidiones to elderly patients with type 2 diabetes due to the risk for bone loss and hip fracture, Morley said. He added how sulfonylureas, such as glipizide (Glucotrol), are not an ideal choice for this population due to their increased risk for hypoglycemia.

GLP-1 agonists, such as liraglutide (Victoza, Saxenda), are effective at A1c reduction, but they may also result in weight loss and therefore are only appropriate for older patients who need both benefits. "Use [of these treatments] in those who are more frail or underweight is not recommended due to the risk of weight loss," Odegard said.

There are also both risks and benefits to using SGLT-2 inhibitors, such as empagliflozin (Jardiance).

"SGLT-2 inhibitors are effective in reducing A1c and have modest effects on weight and blood pressure," Odegard noted, highlighting the recent research that demonstrated the cardiovascular benefits seen with these agents. "However, the associated risk of these agents with urinary tract infections and vaginal candidiasis should be considered prior to use so that these risk are minimized."

"For all agents used to treat diabetes in older adults, attention to renal function with appropriate modification of dose where indicated is important, given the natural decline in renal function that occurs with aging," she said.

Comment