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.
Since these agents are injected, they require intact visual, motor, and cognitive skills and thus may not be appropriate in older patients with cognitive or visual impairment or decreased dexterity. In addition, the high cost of these agents may limit their use.
Select a GLP-1 RA based on the frequency of administration, type of glucose control required (fasting or post-prandial), and the patient’s ability to use the administration device. Dose adjustment is required in renal impairment, except with dulaglutide and liraglutide. Use with caution in patients with a history of pancreatitis, and stop GLP-1 RAs if pancreatitis is suspected during treatment.4 Avoid GLP-1 RAs in patients with a personal or family history of thyroid-related cancers, as these agents have been associated with medullary thyroid tumors in animals.4
A new indication. Recent evidence suggests the GLP-1 RAs may offer additional cardiovascular benefit in patients with diabetes.18,19 In August 2017, liraglutide gained an additional FDA indication to reduce the risk of major adverse cardiovascular events in adults with T2DM and established cardiovascular disease.
This new indication was based on the Novo Nordisk- and National Institutes of Health-sponsored LEADER trial, in which liraglutide reduced the risk of cardiovascular death, nonfatal heart attack, or nonfatal stroke by 13% vs placebo (P=.01) with an absolute risk reduction (ARR) of 1.9%.19 Liraglutide demonstrated a 22% reduction in cardiovascular death and a 15% reduction in all-cause death (ARR 1.3%, 1.4% respectively).19 The new cardiovascular indication may impact the choice of add-on therapy to metformin in patients with preexisting cardiovascular conditions.
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