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Treatment of an elderly patients with diabetes


Authors: Zdeněk Rušavý;  Michal Žourek
Authors‘ workplace: Diabetologické centrum I. interní kliniky LF UK a FN Plzeň, přednosta prof. MUDr. Martin Matějovič, Ph. D.
Published in: Vnitř Lék 2015; 61(4): 321-327
Category: Reviews

Overview

Type 2 diabetes has become a pandemic disease over the past 50 years. Its incidence increases the most rapidly in the senior population, i.e. among people older than 65. In a number of countries 1/4 of the people with diabetes are now older than 65 years. Geriatrics now examines numerous differences regarding the senior patients, which often lead to somewhat different therapeutic procedures as compared to the treatment of other adult patients. This paper aims to show some different aspects of the treatment of an elderly patient with diabetes. The intensity of diabetes treatment in the elderly is mainly defined by the incidence of symptoms caused by diabetic decompensation which negatively affect quali­ty of life and are likely to increase mortality. The treatment goals expressed by HbA1c, fasting and post-prandial glycemia, should be set individually based on age, initial HbA1c, present comorbidities and the level of frailty of an elderly patient. An effort to reduce weight regarding people at an older age is probably inappropriate and maybe even harmful, while physical activity reduces mortality and slows muscle catabolism at every age. Ideal is normal walking for 20–30 minutes a day. Except for “very fit elders” without renal insufficiency, the sulfonylurea treatment is unsuitable and perhaps even harmful. It significantly increases the incidence of different types of hypoglycemia and very likely overall mortality as well. The basis of diabetes treatment for the elderly is the effort to perform any regular exercise. In regard to medication treatment it is recommended to choose metformin or gliptin following the rule “start low, go slow“, i.e. start with low medication doses and increase them at a slow pace. The main goal of the treatment is to maintain the good quality of life as long as possible, without symptoms associated with hyperglycemia with minimizing the risk of hypoglycemia development.

Key words:
diabetes mellitus – diet – frailty – physical activity – gliptin – HbA1c – diabetes treatment – metformin – the elderly – sulphonylurea – older age


Sources

1. UKPDS group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPODS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352(9131): 837–853. Erratum in Lancet 1999; 354(9178): 602.

2. Vijan S, Sussman JB, Yudkin JS et al. The effect of patients´ risk and preferences on health gains with glucose lowering in type 2 diabetes mellitus. JAMA Intern Med 2014; 174(8): 1227–1234.

3. American Diabetes Association. Economic Cost of Diabetes in the U.S. in 2012. Diabetes Care 2013; 36(4): 1033–1046.

4. Fu H, Curtis BH, Xue W et al. Frequency and causes of hospitalization in older compared to younger adults with type 2 diabetes in the United states: A retrospective, claims-based analysis. J Diabetes Complications 2014; 28(4): 477–481.

5. Garg S et al. Poster. 5th International Conference on Advanced Technologies and Treatment for diabetes. Barcelona 2012.

6. Bramlage P, Gitt AK, Binz C et al. Oral antidiabetic treatment in type 2 diabetes in the elderly: balancing the need for glucose control and the risk of hypoglycemia. Cardiovasc Diabetol 2012; 11: 122. Dostupné z DOI: <http://doi: 10.1186/1475–2840–11–122>.

7. Pratley RE, Heller SR, Miller MA. Treatment of type 2 diabetes mellitus in older: a review. Endocr Pract 2014; 20(7): 722–736.

8. Kezerle L, Shalev L, Barski L. Treating the elderly diabetic patient: special considerations. Diabetes Metab Syndr Obes 2014; 7: 391–394.

9. Sinclair AJ, Paolisso G, Castro M et al. European Diabetes Working Party for Older People 2011 clinical guidelines for type 2 diabetes mellitus. Executive summary. Diabetes Metab 2011; 37(Suppl 3): S27-S38.

10. Sinclair A, Morley JE, Rodriguez-Mañas L et al. Diabetes mellitus in older people: position statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People (EDWPOP), and the International Task Force of Experts in Diabetes. J Am Med Dir Assoc 2012; 13(6): 497–502.

11. Svačina Š, Jurašková B, Karen I et al. Doporučené postupy v léčbě starších pacientů s diabetes mellitus v ČR. DMEV 2013; 16(2): 82–89.

12. The Look AHEAD research group: Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013; 369(2): 145–154. Erratum inN Engl J Med. 2014; 370(19): 1866.

13. Winter JE, MacInnis RJ, Wattanapenpaiboon N et al. BMI and all-cause mortality in older adults: a meta-analysis. Am J Clin Nutr 2014; 99(4): 875–890.

14. Moe B, Augestřad LB, Flanders WD et al. The averse association of diabetes with risk of first acute myocardial infarction is modified by physical activity and body mass index: prospective data from the HUNT Study, Norway. Diabetologia 2015; 58(1): 59–66.

15. Li G, Zhang P, Wang J et al. Cardiovascular mortality, all-cause mortality, and diabetes incidence after lifestyle intervention for people with impaired glucose tolerance in the Da Qing Diabetes Prevention Study: a 23-year follow-up study. Lancet Diabetes Endocrinol 2014; 2(6): 474–480.

16. Sui X, LaMonte MJ, Laditka JN et al. Cardiorespiratory fitness and adiposity as mortality predictors in older adults. JAMA 2007; 298(21): 2507–2516.

17. de Jager J, Kooy A, Lehert P et al. Long term treatment with metformin in patients with type 2 diabetes and risk of vitamin B12 deficiency: randomised placebo controlled trial. BMJ 2010; 340: c2181. Dostupné z DOI: <http://doi: 10.1136/bmj.c2181>.

18. Meinert CL, Knatterud GL, Prout TE et al. A study of the effects of hypoglycemic agents on vascular complications in patiens with adult-oneset diabetes II. Mortality results. Diabetes 1970; 19(Suppl): S789-S830.

19. Li Y, Hu Y, Ley SH et al. Sulfonylurea use and incident cardiovascular disease among patients with type 2 diabetes: prospective cohort study among women. Diabetes Care 2014; 37(11): 3106–3113.

20. Mogensen UM, Sndersson CH, Fosbol EL et al. Sulfonylurea in combination with insulin is associated with increased mortality compared with a combination of insulin and metformin in a retrospective Danish nationwide study. Diabetologia 2015; 58(1): 50–58.

21. Patel A MacMahon S, Chalmers J et al. ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008; 358(24): 2560–2572.

22. Duckworth W, Abraira C, Moritz T et al. Intensive glucose control and complications in American veterans with type 2 diabetes. N Engl J Med 2009; 360(2): 129–139.

23. The Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008; 358(24): 2545–2559.

24. Hirshberg B. Raz I. FDA Guidance for Industry. Diabetes mellitus-evaluating cardiovascular risk in new antidiabetic therapies to treat type 2 diabetes. Diabetes Care 2011; 34(Suppl 2): S101-S106.

25. Hung AM, Roumie ChL, Greevy RA et al. Comparative effectiveness of incident oral antidiabetic drugs on kidney function. Kidney Int 2012; 81(7): 698–706.

26. Barzilay N, Guo H, Mahoney EM et al. Efficacy and tolerability of sitagliptin monotherapy in elderly patients with type 2 diabetes: a randomized, doube-blind, placebo-controlled trial. Curr Med Res Opin 2011; 27(5): 1049–1058.

27. Strain WD, Lukashevich V, Kothny V et al. Individualised treatment targets for elderly patients with type 2 diabetes using vildagliptin add-on or lone therapy (INTERVAL): a 24 week, randomised, double-blind, placebo-controlled study. Lancet 2013; 382(9890): 409–416.

28. Barnett AH, Huisman H, Jones R et al. Linagliptin for patients aged 70 years or older with type 2 diabetes inadequately controlled with common antidiabetes treatment: a randomised double-blind, placebo controlled trial. Lancet 2013; 382(9902): 1413–1423.

29. Schwartz SL. Treatment of elderly patients with type 2 diabetes mellitus. A systematic review of the benefits and risks of dipeptidyl peptidase -4 inhibitors. Am J Geriatr Pharmacother 2010; 8(5): 405–418.

30. Schweizer A, Dejager S, Foley JE et al. Clinical experience with vildagliptin in the management of type 2 diabetes in a patient population ≥ 75 years: a pooled analysis from a database of clinical trials. Diabetes Obes Metab 2011; 13(1): 55–64.

31. Schweizer A, Dejager S. Experience with vildagliptin in patients ≥ 75 years with type 2 diabetes and moderate or severe renal impairment. Diabetes Ther 2013; 4(2): 257–267.

32. Thornberry NA, Gallwitz B. Mechanism of action of inhibitors of dipeptidyl-peptidase-4 (DPP-4). Best Pract Res Clin Endocrinol Metab 2009; 23(4): 479–486.

33. Sinclair AJ, Paolisso G, Castro M et al. European Diabetes Working Party for Older People 2011 clinical guidelines for type 2 diabetes mellitus. Executive summary. Diabetes Metab 2011; 37(Suppl 3): S27-S38.

34. Sinclair A, Morley JE, Rodriguez-Mañas L et al. Diabetes mellitus in older people: position statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People (EDWPOP), and the International Task Force of Experts in Diabetes. J Am Med Dir Assoc 2012; 13(6): 497–502.

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Diabetology Endocrinology Internal medicine

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Internal Medicine

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