Diabetes care in those >65yo

The Endocrine Society Clinical Practice Guideline has new recommendations for the treatment of diabetes in people over 65 years old. (see dm older adults guidelines jclinendometab2019 in dropbox, or doi: 10.1210/jc.2019-00198) , with my embedded comments, most in brackets: 

1. specialist referral

-- a specialist should work with those in primary care, along with a multidisciplinary team and the patient,  in the development of individualized treatment goals

    -- my guess is that most of us who see patients >65 yo treat lots of people with diabetes (studies confirm that the incidence of new diabetes is highest in those 65-79 yo). In the vast majority of cases, one does not need the technical input from specialists; however, given the array of comorbidities frequently present in these patients, a multidisciplinary team is usually very helpful, including nutritionists, diabetes care nurses, care managers, etc.

2. screening for diabetes

-- use fasting plasma glucose and/or hemoglobin A1c to screen for diabetes, noting that some comorbidities more prevalent in older people can affect the life span of red blood cells and alter A1c results. If normal screen, repeat in 2 years [not based on specific data]

-- those meeting criteria for prediabetes should get a 2-hour oral glucose tolerance test

    --I don’t think getting the oral glucose tolerance test makes a lot of sense: it is important for anyone who might have prediabetes (and pretty much anyone else) to optimize a healthy lifestyle anyway. And patients who do have prediabetes are not candidates for meds anyway. The guidelines do recommend lifestyle programs similar to the Diabetes Prevention Program, which do focus on weight management, diet, and exercise. Also, recommended intake of calcium and vitamin D. this 2-hr oral GTT is a bit unpleasant (drinking a bottle of sugar water) and one has to wait 2 hours for the blood sample.

3. assessment of patients

--  take into account patients overall health and personal values in determining treatment goals and strategies

-- assess frailty: best to use tools to identify frailty include the Fried score, FRAIL score, and the simple 7-point Clinical Frailty Scale (see http://www.managingmds.com/content/Clinical_Frailty_Scale.pdf for the latter); physical impairment can be measured with the timed “get-up and go” test, 4-m gait speed test, and grip strength with a dynamometer

-- perform periodic cognitive screening, best with a validated self-administered test, at the time of diabetes diagnosis and repeated every 2-3 years (for the validated self-assessment, see dm cognitive test diabmed2016 in dropbox, or Koekkoek PS. Diabet Med 33. 2016: 33: 812)

-- those with cognitive impairment should have a simplified regimen [see below, there are many very simple but very effective regimens, and this should apply to pretty much all patients anyway]

-- focus on medication regimens that minimize the likelihood of hypoglycemia, especially sulfonylureas and glinides, and use insulin sparingly [also, arguably, should apply to all. insulin and sulfonylureas, in many studies, may increase cardiovascular events, as opposed to GLP-1 agonists, which are really effective, do not cause hypoglycemia, and are cardioprotective]

4. goals of therapy

-- in general, those in good health who are not on drugs likely to cause hypoglycemia should have A1c <7.5%; those in intermediate health <8%, and those in poor health <8.5% [not based on rigorous studies. and using GLP-1 agonists, which do not really cause hypoglycemia, i have often had much older patients get significantly lower A1c levels without adverse effects. see more below]

-- those on insulin should have frequent fingerstick glucose monitoring to try to avoid hypoglycemia

5. nutrition

-- important to assess nutritional status [probably best with the help of a trained nutritionist]

-- for those who are frail:

    -- best to have diets rich in protein and energy to prevent malnutrition and weight loss

    -- and best to avoid highly restrictive diets, since thiese can lead to malnutrition. Simply limiting the consumption of simple sugars may be adequate

6. meds

-- Metformin is the initial drug as long as the GFR >30 [I usually find dramatic results with very low dose metformin, such as 500 mg once a day, preferably taken with food to decrease GI toxicity]. see http://gmodestmedblogs.blogspot.com/2019/03/metformin-in-ckd-dec-cv-eventsmortality.html for an array of blogs on metformin

-- in general avoid sulfonylureas and glinides (risk of hypoglycemia)

-- TZDs can cause fluid retention

-- a-glucosidase inhibitors do not much efficacy but do have many GI adverse effects

-- DPP-4’s may be associated with heart failure, and are not very potent

-- SGLT-2’s may be associated with volume depletion; so if use, best to limit dosage

-- GLP-1’s work well but can cause nausea

-- insulin: as noted above, can be associated with hypoglycemia, and best to avoid if possible; if using insulin, make sure that there are frequent blood sugar checks at home

-- In their summary recommendations, they do suggest trying to avoid sulfonylureas and insulin if possible. And they do support using GLP-1 agonists and SGLT-2 inhibittors to be added to first-line metformin

    -- my experience, as alluded to above, has been pretty overwhelmingly positive with GLP-1 agonists, even in patients in their 90s. some with GI side effects or weight loss have done well with reduced dosing. and there have been lots of very dramatic responses in the elderly, with A1c decreasing form the 10 range to <7 in some patients who are unable to change their diet and had terrible responses even to high-dose insulin.

7. hypertension

-- for patients 65-85 years old, target a blood pressure should be 140/90. Might consider 130/80 in those with a previous stroke or progressing chronic kidney disease with eGFR <60 and/or albuminuria. Be careful to avoid orthostatic hypotension. Preferentially use an ACE inhibitor or ARB as first-line therapy

    -- I would add a few points here:

        -- a recent retrospective analysis found that targeting lower blood pressure goals is quite beneficial in those >60 yo: see https://gmodestmedblogs.blogspot.com/2019/01/hypertension-lower-target-is-better.html

        -- a Canadian study of 6000 community dwelling residents >65yo found that much lower blood pressures, down to systolic blood pressure <110 mmHg, was associated work with fewer fatal and nonfatal cardiovascular events: see http://gmodestmedblogs.blogspot.com/2016/10/lower-blood-pressure-in-elderly-and.html

        -- I will add the SPRINT trial, elderly subgroup, finding that those >75 yo did better with an average blood pressure 123/62 then 135/67. However, this trial did not include diabetic patients: see http://gmodestmedblogs.blogspot.com/2016/05/sprint-trial-elderly-subgroup-study-of.html

        -- orthostatic hypotension is a real concern, leading to falls as well as potentially increased risk of dementia: see https://gmodestmedblogs.blogspot.com/2018/09/orthostatic-hypotension-and-dementia.html

            -- so, it is important to check orthostatic blood pressures even in patients who are asymptomatic, since the blood pressure in the office may not fully reflect times at home when the patient is a bit dehydrated at home and at increased  risk of symptomatic hypotension, falls, etc.

            -- and, is important to remember that initial orthostatic hypotension is actually even more common than the standard blood pressure check 2 to 3 minutes later: seehttps://gmodestmedblogs.blogspot.com/2017/08/initial-orthostatic-hypotension-and.html

        -- keep in mind that blood pressure typically decreases with age: see https://gmodestmedblogs.blogspot.com/2018/01/decreasing-blood-pressure-in-elderly.html

        -- they comment on the preference for initial therapy with an ACE inhibitor or ARB. However, the documented benefit of these medications is basically in people have albuminuria.

            -- And, there may be an important role for reducing blood pressure variability, with several studies finding increased  stroke risk in patients on ACE inhibitors, likely related to <24-hour BP control and early-morning blood pressure surges. there have been a few studies looking at blood pressure variability and clinical outcomes (see http://gmodestmedblogs.blogspot.com/2016/09/blood-pressure-variability-increases.html for a pretty recent meta-analysis). And, amlodipine is probably the best med to decrease BP variability (see htn bp variability amlodipine htn2017 in dropbox, or DOI: 10.1161/HYPERTENSIONAHA.117.10087). For example, a Lancet study found that decreasing blood pressure variation in patients led to decreased strokes, noting that strokes happen early in the morning, and that most other antihypertensives do not have good 24-hour blood pressure control (eg ACE-inhibitors); and calcium-channel blockers (most used being amlodipine) had much less blood pressure variability than other classes of BP meds (see htn variability and stroke lancet 2010  in dropbox, or Webb AJS. Lancet 2010; 375: 906).

8. Hyperlipidemia

-- they recommend statin therapy, along with an annual lipid profile. They did not rigorously evaluate the evidence for specific LDL targets, so did not endorse specific goals. However they do comment that if statin therapy is inadequate [not defined] for reaching the chosen LDL goal, one might consider adding ezetimibe or a PCSK9 inhibitor. And in those with fasting triglycerides > 500 mg/dL, they recommend using fish oil and/or fenofibrate to reduce the risk of pancreatitis

    -- a couple of comments:

        -- as noted in several blogs, I really disagree with the concept of “high-intensity statins” as used in the ACC/AHA lipid guidelines: both because in some patients taking lower intensity statins have dramatic reductions in LDL levels and don't need the higher potency ones; and, on the other side, there is a large variation in lipid lowering between atorvastatin 40 mg and rosuvastatin 40 mg (both considered to be “high-intensity”); switching from atorvastatin to rosuvastatin 40 mg has decreased LDL considerably in many of my patients. And, I have used higher doses of statins without a problem in many of my healthier elderly patients who are at higher risk for cardiovascular event. My goals, as discussed with patients, is LDL <100, though for those at higher cardiac risk, mostly <70

        -- there was an interesting observational studies of patients on very low LDL levels finding increasing benefit without harm, though the study was in non-elderly: seehttps://gmodestmedblogs.blogspot.com/2018/08/very-low-ldl-levels-benefit-without-harm.html

        -- that being said, in those >65yo I would still go slowly to decrease the LDL to an appropriate level, given the higher likelihood of adverse effects as people get older

        -- they do comment, appropriately from my perspective, that the LDL numbers can be misleading. Diabetics tend to have the more atherogenic small, dense LDLs; so, a lower total LDL in diabetics may be more atherogenic than a higher one in non-diabetics

9. heart failure management

-- avoid oral hypoglycemic agents than a worsen heart failure: glinides, glitazones, DPP-4 inhibitors (heart failure is really common in diabetics, up to 30% in some studies)

10. aspirin

-- they recommend low-dose aspirin (75 to 162 mg per day) for secondary prevention of cardiovascular disease, after assessing bleeding risks

11. Eye complications

-- annual comprehensive eye exams to detect retinal disease

12. neuropathy

-- avoid meds that could cause sedation or orthostatic hypotension; consider referrals to physical therapy or fall management programs

-- referral to podiatrist/orthopedist/vascular specialist for preventive care to reduce the risk of foot ulceration and amputation

13.chronic kidney disease

-- annual screening with an eGFR and microalbumin in those in good health

so, overall reasonable guidelines, though most of these recommendations are not based on clear studies and are mostly expert opinion. i really support the approach of limiting insulin and using more GLP-1 agonists. but i do think, based on non-definitive studies noted above, that when appropriate, we should try to gingerly lower both blood pressure and cholesterol more aggressively in healthier elderly. and, as always, primarily by assisting patients in lifestyle changes, but secondarily by increasing meds to achieve lower goals

geoff

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