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Diabetes in the Elderly: Matching Meds to Needs

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Diabetes in the Elderly: Matching Meds to Needs Barbara Keber, MD; Jennifer Fiebert, PharmD Hofstra Northwell School of Diabetes in the elderly: Medicine, Northwell Health, Glen Cove, NY Matching meds to needs [email protected] The authors reported no Elderly patients, whose insulin resistance is complicated potential conflict of interest relevant to this article. by age-related loss of beta-cell function and concomitant diseases, require personalized Tx considerations. s members of the baby boomer generation (adults PRACTICE ≥65 years) age, the number of people at risk for dia- RECOMMENDATIONS betes increases. Already nearly one-quarter of people ❯ Allow higher A1C goals for A 1 over age 65 have type 2 diabetes (T2DM). With a proliferation elderly patients who have of new medications to treat diabetes, deciding which ones to such comorbid conditions use in older patients is becoming complex. as cognitive dysfunction, dementia, or cardiovascu- In this article we review the important issues to consider lar or renal disease. B when prescribing and monitoring diabetes medications in older adults. To provide optimal patient-centered care, it’s nec- ❯ Look to metformin first essary to assess comorbid conditions as well as the costs, risks, in most instances if there are no contraindications. and benefits of each medication. Determining appropriate Monitor renal function goals of therapy and selecting agents that minimize the risk of frequently and vitamin B12 hypoglycemia will help ensure safe and effective management levels periodically. B of older patients with diabetes. ❯ Consider glucagon-like peptide-1 receptor agonists for patients who also have What makes elderly patients unique established cardiovascular The pathophysiology of T2DM in the elderly is unique in that disease, or consider starting it involves not just insulin resistance but also age-related loss basal insulin instead of using of beta-cell function, leading to reduced insulin secretion and multiple oral agents. C altered effectiveness of pharmacotherapy.2 The addition of second and third medications may be needed for those with Strength of recommendation (SOR) longstanding T2DM, although these agents often reduce the A Good-quality patient-oriented evidence A1C level to a lesser extent than when used as monotherapy B Inconsistent or limited-quality in patients whose beta-cell function is still intact. In addition patient-oriented evidence to physiologic changes, older adults with diabetes have varied C Consensus, usual practice, opinion, disease-oriented general health statuses and care support systems. The goal for evidence, case series glycemic management should be personalized based on an in- dividual’s comorbidities and physical and cognitive functional status (TABLE 13,4).2 ❚ Higher A1C goals can be acceptable for elderly patients with comorbid conditions such as cognitive dysfunction, de- mentia, or cardiovascular or renal disease. Evaluate cognition when determining appropriate pharmacotherapy. Assess a patient’s awareness of hypoglycemia and ability to adhere to 408 THE JOURNAL OF FAMILY PRACTICE | JULY 2018 | VOL 67, NO 7 TABLE 1 Evidence-based guidelines for diabetes management in the elderly3,4 Health status/patient characteristics A1C goal (%) Treatment considerations Healthy <7.5 Metformin is the first-line medication if not contraindicated. Patient-specific factors determine which agents are appropri- Few coexisting chronic illnesses ate for dual or triple therapy, if indicated, to achieve glycemic Intact cognitive and functional status control. Complex/intermediate <8 For patients with multiple comorbid conditions or a short life expectancy, evaluate the risks and benefits of using antidiabetic Multiple coexisting chronic illnesses medication. Patient-specific factors dictate the choice of medica- Mild to moderate cognitive impairment tion therapy (if indicated to achieve glycemic control). 2 or more instrumental ADL impairments Poor <8.5 Less aggressive A1C goals may be appropriate for many, and discontinuation of medication may be the proper course of Long-term care or end-stage chronic illnesses treatment. This group includes those with severe cardiovascular Moderate to severe cognitive impairment disease, end-stage chronic diseases in addition to diabetes, and life expectancy <5 years. 2 or more ADL dependencies A1C, glycated hemoglobin; ADL, activities of daily living. the regimen prescribed. Visual impairment, failure is a risk factor for adverse events such decreased dexterity, baseline weight, nutri- as lactic acidosis, and metformin is therefore tional and functional status, as well as social contraindicated in patients with an estimated support, finances, and formulary restrictions glomerular filtration rate (eGFR) below should all be considered when determining 30 mL/min/1.73 m2.4 With this in mind, met- the most appropriate regimen for a patient. formin should not be started in patients with Also take into account patient and family an eGFR below 45 mL/min/1.73 m2. And for goals of care.2 TABLE 22-4 summarizes key risks patients already taking metformin, reduce and benefits of the medications we discuss the total daily dose if the eGFR falls to be- next. tween 30 and 45 mL/min/1.73 m2.4 Metformin can cause a reduction in vi- Metformin tamin B12 levels after long-term use in up Metformin is recommended as first-line to 30% of patients, likely due to decreased therapy for those with T2DM for a number of absorption from the ileum.7 Monitor vitamin reasons, including its potential to reduce car- B12 serum concentrations periodically with diovascular events and mortality.3,5 It also sig- long-term therapy, particularly in patients nificantly reduces A1C levels by 1% to 1.5%,6 with peripheral neuropathy or anemia, as while imparting a low risk of hypoglycemia. these conditions may be exacerbated by vita- 3,4 Metformin is cost effective and well tolerated, min B12 deficiency. making it an excellent choice for use in older patients. Sulfonylureas The most common adverse effects are ab- Sulfonylureas increase the secretion of insu- dominal discomfort, diarrhea, and weight loss. lin from pancreatic beta cells, significantly The use of extended-release preparations, as lower blood glucose, and reduce A1C levels well as slow titration of dosing, can improve by 1% to 2%.6 Because hypoglycemia is a se- gastrointestinal (GI) tolerance. Weight loss may rious risk with sulfonylureas, they should be be an attractive side effect in patients who are used conservatively in the elderly.2 Avoid us- overweight or obese, but weight loss and diar- ing sulfonylurea formulations with long half- rhea are concerning effects in frail older adults lives or active metabolites, which can cause who may have poor nutritional reserves.6 severe and prolonged hypoglycemia.8,9 Monitor renal function frequently in Glyburide is broken down into active 3 older patients receiving metformin. Renal metabolites that accumulate in patients MDEDGE.COM/JFPONLINE VOL 67, NO 7 | JULY 2018 | THE JOURNAL OF FAMILY PRACTICE 409 TABLE 2 Pharmacotherapy risks and benefits in the elderly2-4 Class/drug Disadvantages Advantages A1C-lowering Cost potential Metformin • Gastrointestinal adverse effects • Minimal hypoglycemia 1%-1.5% Low • B12 deficiency • Likely reduces both microvascu- lar and macrovascular events • Lactic acidosis (rare) in patients with cardiovascular, renal, or • Weight loss hepatic dysfunction Sulfonylureas • Hypoglycemia (avoid glyburide) • Good initial efficacy 1%-2% Low • Glipizide • Weight gain • Glyburide • Glimepiride TZDs • Weight gain • Minimal hypoglycemia 1%-1.5% Low • Pioglitazone • Edema/heart failure • Improved HDL • Rosiglitazone • Increased fracture risk • Reduced triglycerides (pioglitazone) • Increased LDL • Increased risk of bladder cancer (pioglitazone) DPP-4 inhibitors • Associated with pancreatitis • Minimal hypoglycemia 0.5%-0.9% High • Sitagliptin • Severe joint pain • Well tolerated • Saxagliptin • New or worsening heart failure • Once-daily dosing • Linagliptin • Alogliptin GLP-1 RAs • Injectable • Minimal hypoglycemia 1%-1.5% High • Exenatide • Gastrointestinal adverse effects • Weight loss • Liraglutide • Associated with pancreatitis • Liraglutide may offer cardiovascular benefit • Dulaglutide • Avoid in thyroid cancer • Albiglutide SGLT-2 inhibitors • Genitourinary infections • Minimal hypoglycemia 0.5%-1% High • Canagliflozin • Genital yeast infections • Weight loss • Empagliflozin • Polyuria • Decreased blood pressure • Dapagliflozin • Hyperkalemia • Once-daily dosing • Hypotension • Empagliflozin may offer cardiovascular benefit • Pancreatitis • Increased LDL Insulin • Injectable • Effective in all patients Theoretically High unlimited efficacy • Hypoglycemia • Requires visual, manual, and cognitive skills A1C, glycated hemoglobin; DPP-4, dipeptidyl peptidase-4; GLP-1 RA, glucagon-like peptide-1 receptor agonists; HDL, high-density lipoprotein; LDL, low-density lipoprotein; SGLT-2, sodium glucose cotransporter-2; TZDs, thiazolidinediones. CONTINUED 410 THE JOURNAL OF FAMILY PRACTICE | JULY 2018 | VOL 67, NO 7 who have renal insufficiency; it should be promotes satiety.6 These agents have mod- avoided in older adults due to the risk of life- est efficacy with the potential to lower A1C threatening hypoglycemic events.10 Glipi- by 0.5% to 0.9%.8,13 Studies show that DPP-4 zide has no active metabolites and has the inhibitors are well tolerated with a minimal lowest risk of hypoglycemia in the setting of risk of hypoglycemia in the elderly.13 These decreased renal function, making it
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