Download Shokoufeh Bonakdaran Associate Professor of Endocrinology

Type 2 diabetes mellitus in the
older patient
Shokoufeh Bonakdaran
Associate Professor of Endocrinology
Mashhad university of medical
sciences
16
15.06
12.04
14
% population
12
8.25
10
8
6
4
3.08
2
0.80
0.62
0
Age Group
10
20
30
40
50
60
Risk of aging
• Increased risk of developing of macrovascular
and microvascular complications and excess
morbidity and mortality
• at high risk for polypharmacy, functional
disabilities, cognitive impairment, depression,
urinary incontinence, falls, and persistent pain
Diabetes in old age
• Hyperglycemia increases dehydration and
impairs vision and cognition lead to functional
decline and an increased risk of falling in older
diabetic patients.
• older patients may tolerate relatively higher
blood glucose levels before they manifest an
osmotic diuresis, due to their lower GFRs
• hypoglycemia, can result in poor outcomes
Diabetes goals
• management of both hyperglycemia
and risk factors
• avoidance of hypoglycemia,
hypotension, and drug interactions
due to polypharmacy
• management of coexisting medical
conditions
Glycemic targets
7
8
Target of glycemic control?
• The appropriate target for glycated
hemoglobin (A1C) in fit older patients who
have a life expectancy of over 10 years should
be similar to those developed for younger
adults (<7.0 percent).
• the goal should be higher (≤8.0 percent) in
frail older adults with medical and functional
comorbidities and in those whose life
expectancy is less than 10 years.
• Individualized goals for the very old may be
even higher and should include efforts to
preserve quality of life and avoid
hypoglycemia
Avoiding hypoglycemia
• The risk of hypoglycemia is increased in older
adults.
• older adults may have more neuroglycopenic
manifestations of hypoglycemia (dizziness,
weakness, delirium, confusion) compared with
adrenergic manifestations (tremors, sweating).
• Hypoglycemic episodes in older individuals may
also increase the risk of adverse cardiovascular
events and cardiac autonomic dysfunction
• increased risk of developing dementia
• increase the risk of falls and fracture
CAUTION
• Insulin secretagogues such as sulfonylurea and
meglitinides, as well all types of insulin,
should be used with caution in frail older
adults
nutrition
• medical nutrition evaluation
• Obese older adults with diabetes may benefit
from caloric restriction and an increase in
physical activity with a weight loss goal of
approximately 5 percent of body weight
• Older adults are as much at risk for undernutrition as for obesity. Weight loss increases
the risk of morbidity and mortality in older
adults
Pharmacologic therapy
• must be individualized based upon patient abilities and
comorbidities.
• "Start low and go slow" is a good principle to follow
• For older patients who do not have contraindications,
initiate therapy with metformin
• in patients with contraindications and/or intolerance to
metformin, a short-acting sulfonylurea is an alternative
option ( Glipizide) .
• In a patient with chronic kidney disease who is
intolerant of sulfonylureas, repaglinide could be
considered as initial therapy
Metformin....but
• Increased risk of lactic acidosis.
• Older patients often have impaired renal
function despite an apparently normal serum
creatinine concentration.
• increased risk for myocardial infarction ,stroke,
cardiac failure, pneumonia
• Weight loss and gastrointestinal side effects
may also be limiting factors
caution
• A calculated GFR >30 mL/min has been
suggested as a safe level
• stop taking the drug immediately if they
become ill for any reason, or if they are to
undergo a procedure requiring the use of
iodinated contrast material
Sulfonylurea
• usually well-tolerated.
• Hypoglycemia is the most common side effect
and is more common with long-acting
sulfonylurea drugs (eg, glibenclamide)
• avoid the use of long-acting sulfonylureas in
older adults
Drug-induced hypoglycemia is most
likely to occur
• After exercise or missed meals
• When they eat poorly or abuse alcohol
• When they have impaired renal or cardiac
function or intercurrent gastrointestinal
disease
• During therapy with salicylates, sulfonamides,
fibric acid derivatives and warfarin
• After being in the hospital
Thiazolidinediones
• Pioglitazone improves insulin resistance, also may
increase insulin secretion in response to glucose
• may be considered for some older patients, particularly
those with lower initial A1C values and there are
specific contraindications to sulfonylureas or if they are
not able or willing to consider insulin.
• They can be given to patients who have impaired renal
function
• should not be used in patients with class III or IV heart
failure.
• limited experience, high cost, and concerns regarding
fluid retention, congestive heart failure, MI, and
fractures limit their usefulness, particularly in older
adults
• Pioglitazone is preferred because of the
greater concern about atherogenic lipid
profiles and a potential increased risk for
cardiovascular events with rosiglitazone.
• increased risk for bladder cancer
Meglitinides
• Repaglinide are short-acting glucose-lowering
drug
• similar risk for weight gain as sulfonylureas
but possibly less risk of hypoglycemia
• repaglinide could be considered as initial
therapy in a patient with chronic kidney
disease
alpha-glucosidases inhibitors
• Acarbose inhibits the gastrointestinal alphaglucosidases ( slowing the absorption of
glucose and results in a slower rise in
postprandial blood glucose concentrations)
• Is safe and effective.
• The main side effects are flatulence and
diarrhea
DPP4 inhibitors
• moderately effective as monotherapy or when
used in combination
• relatively weak agents and usually lower A1C
levels by only 0.6 percent.
• have no risk of hypoglycemia and are weightneutral
• Safe?
• relatively expensive.
• The dose of DPP-IV inhibitors should be
adjusted in patients with renal insufficiency.
GLP1 agonists
• as monotherapy or as an adjunct to diet and
exercise or in combination with oral agents
• no risk of hypoglycemia
• significant reduction in weight.
• The most common adverse events are nausea,
vomiting, and diarrhea
• acute pancreatitis and deterioration in renal
function in patients taking GLP-1 therapies
• should not be used in patients with a
creatinine clearance below 30 mL/min
Insulins
• long-acting insulins
• whether or not the patient is physically and
cognitively capable of using an insulin pen or
drawing up and giving the appropriate dose of
insulin, monitoring blood glucose, and
recognizing and treating hypoglycemia?
• Insulin metabolism is altered in patients with
chronic renal failure, so that less insulin is
needed when the GFR is below 50 mL/min.
glycemic goals are not met….
• difficulty adhering to the medication, side
effects, or poor understanding of the nutrition
plan
monitoring
• A1C twice yearly in older patients who are
meeting treatment goals
• quarterly in patients whose therapy has changed
or who are not meeting glycemic goals
• The effectiveness of self-monitoring of blood
glucose in patients with type 2 diabetes is less
clear than for type 1 diabetes
• self-monitoring of glucose may not be necessary
at all, ( for older patients with type 2 diabetes
who are diet-treated or who are treated with oral
agents not associated with hypoglycemia.)
Accuracy of HbA1C?
• may not be accurate
• anemia and other conditions that impact red
blood cell life span
• chronic kidney disease,
• recent transfusions and erythropoietin
infusions
• chronic liver diseases
Retinopathy
• The prevalence of retinopathy increases
progressively with increasing duration of diabetes
• 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 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
Nephropathy
• all patients with diabetes be screened for
increased urinary albumin excretion annually.
• 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 ACE receptor blocker, it may not be
necessary or helpful to continue testing for
increased urinary albumin excretion on an annual
basis.
Diabetic foot
• more than 30 percent of older diabetic
patients cannot see or reach their feet
• older diabetic patients should their feet
examined at every visit
• A detailed neurologic examination and
assessment for peripheral artery disease
should be performed at least yearly.
CHD is by far the leading cause of
death in older patients
• Risk reduction should be focused upon the
following areas:
• Smoking cessation
• Treatment of hypertension
• Treatment of dyslipidemia
• ASPIRIN therapy
• Exercise
summary
• The appropriate target for glycated hemoglobin
(A1C) in fit older patients who have a life
expectancy of over 10 years should be similar to
those developed for younger adults (<7.0
percent).
• The goal should be somewhat higher (≤8.0
percent) in frail older adults with multiple
medical and functional comorbidities and in
those whose life expectancy is less than 10 year
Summary 2
• The risk of hypoglycemiais substantially
increased in older adults.
• avoidance of hypoglycemia is an important
consideration