Construction of Effective and Safe Glycemic Control in the Elderly by Using Continuous Glucose Monitoring

Elmer ress Letter to the Editor J Endocrinol Metab. 2017;7(3):98-99

Koki Kakutaa, b, Hiroki Adachia, b, Hidekatsu Yanaia, c

To the Editor switching from repaglinide to voglibose on glycemic control in Figure 1. CGM showed hypoglycemia early at morning (from 2 to 6 o’clock in the morning) (Fig. 1a, b) during the treatment Severe hypoglycemia is significantly associated with increased using repaglinide. After the switching to voglibose, hypoglyce- risks of a range of adverse clinical outcomes [1]. An increased mia early at morning was disappeared (Fig. 1c, d). In addition, risk for developing dementia by older patients with diabetes maximal glucose level and amplitude of glucose excursion de- who have had episode of severe hypoglycemia has been sug- creased, in spite of reduction of insulin dose (Fig. 1d). gested [2]. Further, patients with dementia and diabetes appear Repaglinide is a short-acting, insulin-releasing agent, and to be at greater risk for severe hypoglycemia [2]. However, has been suggested to lessen the risk of long-lasting hypoglyce- excellent evidence on glycemic control in the elderly is lack- mia [5], however, which was observed in our patient. We should ing, and optimal treatment needs to be constructed collabo- consider the development of severe hypoglycemia in the elderly ratively with patients, incorporating the likelihood of benefits whose drug clearance is diminished when we use glinides. Fur- and harms and patients preferences about treatment in older thermore, our observation indicated that α-GI does not induce adults with type 2 diabetes [3]. long-lasting hypoglycemia and also ameliorates glycemic con- To show the usefulness of continuous glucose monitoring trol in combination with insulin as compared with glinides. (CGM) to determine safe and effective glycemic control in the We think that benefits and harms about treatment for dia- elderly, we present our old patient who showed asymptomatic betes depend largely on individuals, and individual differences severe hypoglycemia during sleeping. An 83-year-old type 2 get larger by aging. Therefore, we strongly recommend the diabetic female patient (body height, 151.4 cm; body weight, 2 construction of safe and effective glycemic control in the el- 56.7 kg; BMI, 24.7 kg/m ) was admitted to our hospital due derly by using CGM. to poor glycemic control. She has been treated by ingestion of alogliptin (25 mg) before breakfast, and repaglinide (1.0 mg) before every meal, and injection of insulin glargine U300 (10 Conflicts of Interest U) before breakfast. On admission, her plasma glucose and HbA1c level were 334 mg/dL and 8.7%, respectively. We changed insulin treatment from insulin glargine U300 The authors declare that they have no conflicts of interest con- (10 U) to insulin degludec (IDeg)/insulin aspart (IAsp) (14 cerning this article. U) which is a soluble conformation of two distinct insulin analogues in the ratio of 70% ultra-long-acting IDeg and 30% References rapid-acting IAsp [4]. We stopped ingestion of repaglinide before breakfast because of the addition of IAsp before breakfast. 1. Zoungas S, Patel A, Chalmers J, de Galan BE, Li Q, We also switched from repaglinide (1.0 mg before lunch and Billot L, Woodward M, et al. Severe hypoglycemia dinner) to α-glucosidase inhibitor (α-GI), voglibose (0.3 mg and risks of vascular events and death. N Engl J Med. before lunch and dinner). 2010;363(15):1410-1418. We present the result of CGM which showed the effect of 2. Meneilly GS, Tessier DM. Diabetes, Dementia and Hypo- glycemia. Can J Diabetes. 2016;40(1):73-76. Manuscript submitted May 16, 2017, accepted May 30, 2017 3. Lipska KJ, Krumholz H, Soones T, Lee SJ. Polyp- harmacy in the Aging Patient: A Review of Glycemic aDepartment of Internal Medicine, National Center for Global Health and Control in Older Adults With Type 2 Diabetes. JAMA. Medicine Kohnodai Hospital, Chiba, Japan 2016;315(10):1034-1045. bThese authors equally contributed to this work. c 4. Ma Z, Parkner T, Christiansen JS, Laursen T. IDegAsp: a Corresponding Author: Hidekatsu Yanai, Department of Internal Medicine, novel soluble insulin analogs combination. Expert Opin National Center for Global Health and Medicine Kohnodai Hospital, 1-7-1 Kohnodai, Ichikawa, Chiba 272-0034, Japan. Biol Ther. 2012;12(11):1533-1540. Email: [email protected] 5. Guay DR. Repaglinide, a novel, short-acting hypoglyce- mic agent for type 2 diabetes mellitus. Pharmacotherapy. doi: https://doi.org/10.14740/jem425w 1998;18(6):1195-1204.

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Figure 1. Continuous glucose monitoring showing the effect of switching from repaglinide to voglibose for the treatment for type 2 diabetes in old women.