Diabetes in the elderly: Matching meds to needs
Elderly patients, whose insulin resistance is complicated by age-related loss of beta-cell function and concomitant diseases, require personalized Tx considerations.
PRACTICE RECOMMENDATIONS
› Allow higher A1C goals for elderly patients who have such comorbid conditions as cognitive dysfunction, dementia, or cardiovascular or renal disease. B
› Look to metformin first in most instances if there are no contraindications. Monitor renal function frequently and vitamin B12 levels periodically. B
› Consider glucagon-like peptide-1 receptor agonists for patients who also have established cardiovascular disease, or consider starting basal insulin instead of using multiple oral agents. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
From The Journal of Family Practice | 2018;67(7):408-410,412-415.
Combining antidiabetes agents
However, for older patients already taking metformin who are not at their A1C goal, consider adding a second agent, if not contraindicated. Potential agents include a GLP-1 RA, SGLT-2 inhibitor, DDP-4 inhibitor, or short-acting sulfonylurea (glipizide). Alternatively, basal insulin may be added. However, avoid combining a sulfonylurea with insulin, which greatly increases the risk of hypoglycemia.32 Consider adding a GLP-1 RA or basal insulin if the patient is not at his/her target A1C on oral therapy with multiple agents.3
CORRESPONDENCE
Barbara Keber, MD, Glen Cove Hospital, 101 St. Andrews Lane, Glen Cove, NY; bkeber@northwell.edu.
