New guideline emphasizes simpler diabetes regimens, looser glycemic targets for older adults
NEW ORLEANS — Treatment of diabetes in older adults remains a challenge, and a new guideline from the Endocrine Society recommends simplified medication regimens and looser glycemic targets to improve adherence and prevent treatment-related complications in this patient population.
Above all, the new guidance emphasizes shared decision-making and individualized treatment goals for older adults — classified by the guideline as those aged 65 years and older.
“The prevalence of type 2 diabetes increases as individuals age and exaggerates the incidence of both microvascular and macrovascular complications,” Derek LeRoith, MD, PhD, professor of medicine in the Hilda and J. Lester Gabrilove Division of Endocrinology, Diabetes and Bone Diseases at Icahn School of Medicine at Mount Sinai, said during a presentation at ENDO 2019.
“The problems that older individuals face, in contrast to younger people with the disease, include sarcopenia, frailty and cognitive dysfunction. Such complications can lead to increased risk of poor medication adherence, hypoglycemia from certain medications, falls and loss of independence in daily living activities.”
The incidence of newly diagnosed diabetes is highest among those aged 65 to 79 years, particularly type 2 diabetes, which is estimated to affect 33% of U.S. older adults, according to the guideline authors. Moreover, more than 50% of older adults meet criteria for prediabetes.
“Prediabetes is highly prevalent in older people; however, interventions to delay progression from prediabetes to diabetes are especially effective in this age group,” LeRoith said.
The guideline focuses on treatment strategies that take into consideration the overall health and quality of life of older adults with diabetes, according to a press release.
Regular screening. Regular screening for prediabetes and diabetes in older adults is recommended, with collaboration between an endocrinologist or diabetes care specialist and the primary care provider, a multidisciplinary team and the patient to individualize treatment goals.
Cognition. Periodic cognitive screening to identify undiagnosed cognitive impairment should be performed in this older population. The guideline authors recommend initial cognitive screening at the time of diagnosis or entry into a care program, with repeat screening every 2 to 3 years following a normal screening test result. Evaluation of cognitive impairment and assessment of cognition should be performed in older patients with complaints.
Simplified regimens and targets. Particularly among older patients with a history of cognitive impairment, such as dementia, the guideline recommends that medication regimens be simplified and glycemic targets tailored so they are more lenient, with the goal to improve compliance and prevent complications related to treatment. Designing outpatient diabetes regimens to specifically minimize hypoglycemia and tailoring glycemic targets to overall health and management strategies may be beneficial.
Lifestyle intervention. Lifestyle modification is recommended as the first-line treatment for hyperglycemia in ambulatory older adults. Other lifestyle recommendations include assessing nutritional status to detect or manage malnutrition, a diet rich in protein and energy, and avoidance of restrictive diets and limited simple sugars for older patients at risk for malnutrition.
Therapy options. Metformin is recommended as the initial oral medication, in addition to lifestyle management, excluding patients with impaired kidney function or gastrointestinal intolerance. For those requiring more than metformin and lifestyle modification to achieve glycemic targets, other oral or injectable agents and/or insulin can be added. The guideline advises avoiding sulfonylureas, glinides and glyburide, and using insulin only sparingly in this patient population. The guideline features a helpful table of medications used to treat hyperglycemia and special concerns with use in older patients with cardiovascular disease and chronic kidney disease.
Overall, the authors note that “glycemic treatment regimens should be kept as simple as possible.”
Blood pressure. A target BP of 140/90 mm Hg is recommended for patients aged 65 to 85 years to decrease risk for CVD outcomes, stroke and progressive kidney disease. A lower target can be considered in certain high-risk patients, such as those with a history of stroke or progressing kidney disease. A higher BP target can be considered for patients with high disease complexity. An angiotensin-converting enzyme inhibitor or angiotensin receptor blocker should be the first-line therapy for older patients with hypertension and diabetes.
“Choosing a blood pressure target involves shared decision-making between the clinician and patient, with full discussion of the benefits and risks of each target,” the authors wrote in the Journal of Clinical Endocrinology and Metabolism.
Hyperlipidemia. An annual lipid profile and statin therapy can be used to lower levels of LDL cholesterol to reduce risk for CVD events and mortality. For those who require additional treatment beyond statins, ezetimibe or PCSK9 inhibitors can be considered. The guideline authors note that they did not endorse LDL cholesterol targets for this population; however, “[f]or patients aged 80 years old and older or with a short life expectancy, we advocate that LDL cholesterol goal levels should not be so strict.”
Eye complications. Annual comprehensive eye examinations by an ophthalmologist or optometrist are recommended to detect retinal disease.
Patients in special settings. The guideline also addresses treatment of patients in hospitals and long-term facilities, again emphasizing simplified treatment for those with a terminal illness or severe comorbidities. Clear targets for glycemia are recommended for patients in these settings: 100 to 140 mg/dL fasting and 140 to 180 mg/dL after meals while avoiding hypoglycemia.
The guideline also provides recommendations for neuropathy, falls, lower-extremity problems, chronic kidney disease, heart failure and aspirin treatment.
At ENDO 2019, LeRoith said the new guideline essentially emphasizes “personalized medicine, where the individual patient gets treated to his or her situation.
“Given the heterogeneity of the health status of older people with diabetes, the guideline emphasizes shared decision-making and provides a framework to assist health care providers to individualize treatment goals,” he said.
During the session, moderator Anne Peters, MD, professor of clinical medicine at Keck School of Medicine of the University of Southern California and director of the USC Clinical Diabetes Programs, said “this is going to be a very useful tool because it defines things that haven’t been previously defined [in guidelines], in terms of how we approach the older patients with both prediabetes and diabetes and then what to do moving forward with treatment.” – by Katie Kalvaitis
LeRoith D, et al. Treatment of Diabetes in Older Adults: An Endocrine Society Clinical Practice Guideline. Presented at: The Endocrine Society Annual Meeting; March 23-26, 2019; New Orleans.
Disclosures: LeRoith reports he is a consultant for AstraZeneca and MannKind is on an advisory board for AstraZeneca. Peters reports she is on advisory boards for Abbott Laboratories, Eli Lilly & Company, Lexicon Pharmaceuticals, Mannkind Corporation, Merck, Novo Nordisk and Sanofi, is a recipient of grants from AstraZeneca, Mannkind Corporation and Dexcom and is a speaker for Novo Nordisk.