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Clinical Challenges of Diabetes in Older People: Goals of Care

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Dr Sanjiv Shah, Mumbai    24 November 2018

  1. The prevalence of diabetes is rising in the >65 year-old age group.
  2. Diabetes in older people poses several challenges. The challenges include heterogeneity, hypoglycemia risk, complications, polypharmacy, sparse clinical data and different goals of therapy. Metformin is a potential first-line therapy. It has low potential for hypoglycemia, improves lipid profile and offers potential CV benefits.
  3. Modern SUs with a lower risk of hypoglycemia such as glimepiride and gliclazide XR (low-dose) are recommended in elderly patients. Insulin is underutilized in elderly patients due to concerns about hypoglycemia, misconceptions about insulin, social stigma, needle phobia and complexity of injection skills.
  4. GLP-1 receptor agonists in elderly – They are well-tolerated without increasing the risk of hypoglycemia. They delay gastric emptying and increase satiety. Early use may be beneficial to obese diabetic elderly but may be detrimental for the frail patients with poor caloric intake.
  5. SGLT2i can be used as a monotherapy as well as combination therapy. Added benefits include weight loss, improved blood pressure and lipid parameters.
  6. DPP-4i inhibit DPP-4, prolong the action of GLP-1 and glucose-dependent insulinotropic peptide. They lead to reductions in HbA1c for patients with higher baseline HbA1c levels. They have excellent tolerability profiles, low-risk of hypoglycemia and are safe to be used in renal impairment. Vildagliptin has been shown to reduce glucose fluctuations and the risk of hypo-/hyperglycemia. There is minimal risk of hypoglycemia with vildagliptin as add-on to insulin therapy. Vildagliptin improves glycemic control in hemodialyzed T2DM patients.
  7. DPP-4i are the choice of therapy in elderly T2DM patients: There is robust clinical evidence supporting their role in the elderly; they are associated with minimal risk of hypoglycemia; they control glycemic variability; they yield CV benefits including HF; and they are safe for use in patients with renal impairment.
  8. Vildagliptin data were used to show all the benefits.

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