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Treatment of Diabetes in Older Adults: an Endocrine Society* Clinical Practice Guideline

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Treatment of Diabetes in Older Adults: an Endocrine Society* Clinical Practice Guideline CLINICAL PRACTICE GUIDELINE Treatment of Diabetes in Older Adults: An Endocrine Society* Clinical Practice Guideline Derek LeRoith,1 Geert Jan Biessels,2 Susan S. Braithwaite,3,4 Felipe F. Casanueva,5 Boris Draznin,6 Jeffrey B. Halter,7,8 Irl B. Hirsch,9 Marie E. McDonnell,10 Mark E. Molitch,11 M. Hassan Murad,12 and Alan J. Sinclair13 Downloaded from https://academic.oup.com/jcem/article-abstract/104/5/1520/5413486 by guest on 07 April 2020 1Icahn School of Medicine at Mount Sinai, New York, New York 10029; 2University Medical Center Utrecht, 3584 CX Utrecht, Netherlands; 3Presence Saint Francis Hospital, Evanston, Illinois 60202; 4Presence Saint Joseph Hospital, Chicago, Illinois 60657; 5Complejo Hospitalario Universitario de Santiago, CIBER de Fisiopatologia Obesidad y Nutricion, Instituto Salud Carlos III, 15782 Santiago de Compostela, Spain; 6University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado 80045; 7University of Michigan, Ann Arbor, Michigan 48109; 8National University of Singapore, Singapore 119077, Singapore; 9University of Washington Medical Center–Roosevelt, Seattle, Washington 98105; 10Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115; 11Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611; 12Division of Preventive Medicine, Mayo Clinic, Rochester, Minnesota 55905; and 13King’s College, London SE1 9NH, United Kingdom ORCiD numbers: 0000-0002-7920-8474 (D. LeRoith). *Cosponsoring Associations: European Society of Endocrinology, The Gerontological Society of America, and The Obesity Society. Objective: The objective is to formulate clinical practice guidelines for the treatment of diabetes in older adults. Conclusions: Diabetes, particularly type 2, is becoming more prevalent in the general population, especially in individuals over the age of 65 years. The underlying pathophysiology of the disease in these patients is exacerbated by the direct effects of aging on metabolic regulation. Similarly, aging effects interact with diabetes to accelerate the progression of many common diabetes compli- cations. Each section in this guideline covers all aspects of the etiology and available evidence, primarily from controlled trials, on therapeutic options and outcomes in this population. The goal is to give guidance to practicing health care providers that will benefit patients with diabetes (both type 1 and type 2), paying particular attention to avoiding unnecessary and/or harmful adverse effects. (J Clin Endocrinol Metab 104: 1520–1574, 2019) ISSN Print 0021-972X ISSN Online 1945-7197 Abbreviations: ACE, angiotensin-converting enzyme; ACCORD, Action to Control Car- Printed in USA diovascular Risk in Diabetes; ADA, American Diabetes Association; ADL, activity of daily Copyright © 2019 Endocrine Society living; ARB, angiotensin receptor blocker; BP, blood pressure; CGM, continuous glucose Received 25 January 2019. Accepted 25 January 2019. monitoring; CHF, congestive heart failure; CKD, chronic kidney disease; CVD, cardio- First Published Online 23 March 2019 vascular disease; DPP-4, dipeptidyl peptidase-4; eGFR, estimated glomerular filtration rate; FDA, Food and Drug Administration; GLP-1, glucagon-like-peptide 1; GFR, glo- merular filtration rate; HR, hazard ratio; IADL, instrumental ADL; LDL-C, low-density li- poprotein cholesterol; LTCF, long-term care facility; MACE, major adverse cardiovascular event; MCI, mild cognitive impairment; PCSK9, proprotein convertase subtilisin/kexin type 9; RCT, randomized control trial; RR, relative risk; SGLT2, sodium-glucose cotransporter 2; SBP, systolic blood pressure; SDM, shared decision-making; SPRINT, Systolic Blood Pressure Intervention Trial; SU, sulfonylurea; T1D, type 1 diabetes; T2D, type 2 diabetes; UKPDS, UK Prospective Diabetes Study; VEGF, vascular endothelial growth factor. 1520 https://academic.oup.com/jcem J Clin Endocrinol Metab, May 2019, 104(5):1520–1574 doi: 10.1210/jc.2019-00198 doi: 10.1210/jc.2019-00198 https://academic.oup.com/jcem 1521 List of Recommendations American, Asian American, Pacific Islander), history of cardiovascular disease, hypertension Role of the endocrinologist and diabetes ($140/90 mm Hg or on therapy for hypertension), care specialist high-density lipoprotein cholesterol level ,35 mg/dL . 1.1 In patients aged 65 years and older with newly (0.90 mmol/L) and/or a triglyceride level 250 diagnosed diabetes, we advise that an endocri- mg/dL (2.82 mmol/L), sleep apnea, or physical nologist or diabetes care specialist should work inactivity. Shared decision-making is advised for with the primary care provider, a multidisciplinary performing this procedure in frail older people or team, and the patient in the development of in- in those for whom it may be overly burdensome. dividualized diabetes treatment goals. (Ungraded Standard dietary preparation for an oral glucose Downloaded from https://academic.oup.com/jcem/article-abstract/104/5/1520/5413486 by guest on 07 April 2020 Good Practice Statement) tolerance test is advised. 1.2 In patients aged 65 years and older with diabetes, 2.3 In patients aged 65 years and older who have an endocrinologist or diabetes care specialist prediabetes, we recommend a lifestyle program should be primarily responsible for diabetes care similar to the Diabetes Prevention Program to ÈÈÈÈ if the patient has type 1 diabetes, or requires complex delay progression to diabetes. (1| ) hyperglycemia treatment to achieve treatment goals, Technical remark: Metformin is not recommended or has recurrent severe hypoglycemia, or has multiple for diabetes prevention at this time, as it is not diabetes complications. (Ungraded Good Practice approved by the Food and Drug Administration for Statement) this indication. As of 2018, a Diabetes Prevention Program–like lifestyle intervention is a covered benefit for Medicare beneficiaries in the United Screening for diabetes and prediabetes, and States who meet the criteria for prediabetes. diabetes prevention 2.1 In patients aged 65 years and older without known Assessment of older patients with diabetes diabetes, we recommend fasting plasma glucose and/or HbA1c screening to diagnose diabetes or 3.1 In patients aged 65 years and older with diabetes, prediabetes. (1|ÈÈÈÈ) we advise assessing the patient’s overall health Technical remark: The measurement of HbA1c (see Table 2) and personal values prior to the may be inaccurate in some people in this age determination of treatment goals and strategies (see group because of comorbidities that can affect the Table 3). (Ungraded Good Practice Statement) lifespan of red blood cells in the circulation. Al- 3.2 In patients aged 65 years and older with diabetes, though the optimal screening frequency for pa- we suggest that periodic cognitive screening tients whose initial screening test is normal should be performed to identify undiagnosed remains unclear, the writing committee advocates cognitive impairment. (2|ÈÈOO) repeat screening every 2 years thereafter. As with Technical remark: Use of validated self-administered any health screening, the decision about diabetes tests is an efficient and cost-effective way to imple- and prediabetes screening for an individual patient ment screening (see text). Alternative screening test depends on whether some action will be taken as a options, such as the Mini-Mental State Examination result and the likelihood of benefit. For example, or Montreal Cognitive Assessment, are widely used. such screening may not be appropriate for an older An initial screening should be performed at the time patient with end-stage cancer or organ system of diagnosis or when a patient enters a care program. failure. In these situations, shared decision-making Screening should be repeated every 2 to 3 years with the patient is recommended. after a normal screening test result for patients 2.2 In patients aged 65 years and older without without cognitive complaints or repeated 1 year known diabetes who meet the criteria for pre- after a borderline normal test result. Always evaluate diabetes by fasting plasma glucose or HbA1c, we cognitive complaints and assess cognition in patients suggest obtaining a 2-hour glucose post–oral with complaints. glucose tolerance test measurement. (2|ÈÈÈO) 3.3 In patients aged 65 years and older with diabetes Technical remark: This recommendation is most and a diagnosis of cognitive impairment (i.e., mild applicable to high-risk patients with any of the cognitive impairment or dementia), we suggest following characteristics: overweight or obese, that medication regimens should be simplified (see first-degree relative with diabetes, high-risk race/ recommendation 3.1) and glycemic targets tailored ethnicity (e.g., African American, Latino, Native (i.e., be more lenient; see recommendation 4.1) to 1522 LeRoith et al Diabetes in Older Adults Guidelines J Clin Endocrinol Metab, May 2019, 104(5):1520–1574 improve compliance and prevent treatment-related protein and energy to prevent malnutrition and complications. (2|ÈÈOO) weight loss. (2|ÈÈOO) Technical remark: Medical and nonmedical 4.6 In patients aged 65 years and older with diabetes treatment and care for cognitive symptoms in who cannot achieve glycemic targets with lifestyle people with diabetes and cognitive impairment modification, we suggest avoiding the use of re- are no different from those in people without strictive diets and instead limiting consumption of diabetes and cognitive impairment. Depending on simple sugars if patients are at risk for malnu- the
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