Management of hypoglycemia in older adults with type 2 diabetes

Hypoglycaemia and Cardiovascular Disease Risk in Patients with Diabetes

Hypoglycaemia represents an important side effect of insulin therapy and insulin secretagogues. It can occur in both type 1 and type 2 diabetes mellitus patients. Also, some associations between hypoglycaemia and cardiovascular (CV) risk have been reported. Several mechanisms may be involved, including the sympathoadrenal system, hypokalaemia, endothelial dysfunction, coagulation, platelets, inflammation, atherothrombosis and impaired autonomic cardiac reflexes. This narrative review discusses the associations of hypoglycaemia with CV diseases, including coronary heart disease (CHD), cardiac arrhythmias, stroke, carotid disease and peripheral artery disease (PAD), as well as with dementia. Severe hypoglycaemia has been related to CHD, CV and all-cause mortality. Furthermore, there is evidence supporting an association between hypoglycaemia and cardiac arrhythmias, potentially predisposing to sudden death. The data linking hypoglycaemia with stroke, carotid disease and PAD is limited. Several factors may affect the hypoglycaemia-CV relationships, such as the definition of hypoglycaemia, patient characteristics, co-morbidities (including chronic kidney disease) and antidiabetic drug therapy. However, the association between hypoglycaemia and dementia is bilateral. Both the disorders are more common in the elderly; thus, glycaemic goals should be carefully selected in older patients. Further research is needed to elucidate the impact of hypoglycaemia on CV disease.

Nutritional guidelines for the management of insulin resistance

Obesity and its related co-morbidities, namely type 2 diabetes (T2D), pose a significant global public health problem. Insulin resistance (IR) in muscle and liver is the core pathophysiologic defect that underlies obesity preceding and predicting the onset of T2D in susceptible humans. There is a broad population with IR that has no indication for prescription of medications, who still need medical consultation and specific advice in this respect. This prevalent need can be achieved by appropriate diet, exercise, and other behavioral therapies for lifestyle interventions. Despite a well-recognized role of IR in the progression to metabolic diseases, no specific nutritional recommendations exist to manage this condition, to the best of our knowledge. An international panel of experts reviewed and critically appraised the updated literature published about this topic. This review primarily examines the evidence for areas of consensus and ongoing uncertainty or controversy about diet and exercise approaches for IR. The aim of this article is to present the most common IR states, namely obesity and Polycystic Ovary Syndrome (PCOS), and provide nutritional advice to manage IR, hyperinsulinemia, and reactive hypoglycemia. These nutritional guidelines could prevent progression or worsening of IR with resultant beta-cell failure and, as a result, T2D.

Association between plasma betaine levels and dysglycemia in patients with coronary artery disease

Background: Dietary betaine intake was reported to associate with favorable profile of metabolic disorders. However, the role of circulating betaine in coronary artery disease (CAD) patients with dysglycemia is still unknown. The present study aimed to investigate the potential associations between plasma betaine levels and dysglycemia in CAD patients.

Methods: Total 307 subjects were enrolled in the present study with 165 CAD patients (57 with dysglycemia and 108 with normal glycemia) and 142 age- and sex-matched controls (CON). Fasting plasma betaine was detected using liquid chromatography tandem mass spectrometry.

Results: Plasma betaine was lower in normal glycemia CAD patients (28.29 (22.38–35.73) μM) compared with healthy controls (29.75 (25.32–39.15) μM), and was further decreased in CAD patients with dysglycemia (24.14 (20.84–30.76) μM, P<0.01). Betaine levels were inversely correlated with fasting glucose, glycated hemoglobin% (HbA1c), diastolic blood pressure (DBP), triglyceride (TG) and alanine aminotransferase (ALT) levels (all, P≤0.05). Subjects in the highest betaine tertile group had lowest frequency of CAD and dysglycemia (all, P<0.01). Increased betaine levels were independently associated with low risk of dysglycemia in CAD after adjustment for multiple traditional risk factors (OR = 0.04, 95% CI: 0–0.37, P=0.01). Furthermore, betaine had good performance at distinguishing CAD with dysglycemia from normal glycemia CAD (AUC = 0.62, P<0.01).

Conclusion: Plasma betaine levels are independently and inversely associated with dysglycemia in CAD after adjustment for multiple factors, and may be useful for risk stratification of dysglycemia in CAD.

Cardiovascular outcomes and safety with linagliptin, a dipeptidyl peptidase-4 inhibitor, compared with the sulphonylurea glimepiride in older people with type 2 diabetes: A subgroup analysis of the randomized CAROLINA trial

AIM

To compare the cardiovascular (CV) safety of linagliptin with glimepiride in older and younger participants in the CAROLINA trial in both prespecified and post hoc analyses.

MATERIALS AND METHODS

People aged 40 to 85 years with relatively early type 2 diabetes, inadequate glycaemic control and elevated CV risk were randomly assigned to linagliptin 5 mg or glimepiride 1 to 4 mg. The primary endpoint was time to first occurrence of three-point major adverse CV events (MACE: CV death, non-fatal myocardial infarction, or non-fatal stroke). We evaluated clinical and safety outcomes across age groups.

RESULTS

Of 6033 participants, 50.7% were aged <65 years, 35.3% were aged 65 to 74 years, and 14.0% were aged ≥75 years. During the 6.3-year median follow-up, CV/mortality outcomes did not differ between linagliptin and glimepiride overall (hazard ratio [HR] for three-point MACE 0.98, 95.47% confidence interval [CI] 0.84, 1.14) or across age groups (interaction P >0.05). Between treatment groups, reductions in glycated haemoglobin were comparable across age groups but moderate-to-severe hypoglycaemia was markedly reduced with linagliptin (HR 0.18, 95% CI 0.15, 0.21) with no differences among age groups (P = 0.23). Mean weight was -1.54 kg (95% CI -1.80, -1.28) lower for linagliptin versus glimepiride. Adverse events increased with age, but were generally balanced between treatment groups. Significantly fewer falls or fractures occurred with linagliptin.

CONCLUSIONS

Linagliptin and glimepiride were comparable for CV/mortality outcomes across age groups. Linagliptin had significantly lower risk of hypoglycaemia and falls or fractures than glimepiride, including in "older-old" individuals for whom these are particularly important treatment considerations.

A prospective six-month audit of inpatient hypoglycemia in step-down general medical and geriatric wards

This study aimed to assess the incidence and associates of hypoglycemia in patients transferred after stabilization on an Acute Medical Unit to two general medical or two geriatric wards at an urban Australian hospital. In a six-month audit representing 20,284 patient-days of observation, 59 inpatients experienced hypoglycaemia (blood glucose ≤3.9 mmol/L) during 65 hospitalizations. Inpatients experiencing hypoglycemia accounted for 7.2% of all inpatient bed-days, a figure that was greater for general medical (9.2% of bed-days) compared with geriatric (6.0% of bed-days) wards (P<0.001). Inpatient hypoglycemia often had no precipitant such as a missed/delayed meal, occurred disproportionately at night (41% of episodes), was severe (blood glucose ≤3.0 mmol/L) in one-third of cases, and appeared more frequent in patients with psychiatric/cognitive issues. These data highlight the ongoing issue of hypoglycemia in relatively stable inpatients in an era of blood glucose-lowering therapies associated with a low rate of this acute metabolic complication.

No significant association between dipeptidyl peptidase-4 inhibitors and adverse outcomes of COVID-19

BACKGROUND

Dipeptidyl peptidase-4 (DPP4) is commonly targeted to achieve glycemic control and has potent anti-inflammatory and immunoregulatory effects. Recent structural analyses indicated a potential tight interaction between DPP4 and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), raising a promising hypothesis that DPP4 inhibitor (DPP4i) drugs might be an optimal strategy for treating coronavirus disease 2019 (COVID-19) among patients with diabetes. However, there has been no direct clinical evidence illuminating the associations between DPP4i use and COVID-19 outcomes.

AIM

To illuminate the associations between DPP4i usage and the adverse outcomes of COVID-19.

METHODS

We conducted a multicenter, retrospective analysis including 2563 patients with type 2 diabetes who were hospitalized due to COVID-19 at 16 hospitals in Hubei Province, China. After excluding ineligible individuals, 142 patients who received DPP4i drugs and 1115 patients who received non-DPP4i oral anti-diabetic drugs were included in the subsequent analysis. We performed a strict propensity score matching (PSM) analysis where age, sex, comorbidities, number of oral hypoglycemic agents, heart rate, blood pressure, pulse oxygen saturation (SpO2) < 95%, CT diagnosed bilateral lung lesions, laboratory indicators, and proportion of insulin usage were matched. Finally, 111 participants treated with DPP4i drugs were successfully matched to 333 non-DPP4i users. Then, a linear logistic model and mixed-effect Cox model were applied to analyze the associations between in-hospital DPP4i use and adverse outcomes of COVID-19.

RESULTS

After rigorous matching and further adjustments for imbalanced variables in the linear logistic model and Cox adjusted model, we found that there was no significant association between in-hospital DPP4i use (DPP4i group) and 28-d all-cause mortality (adjusted hazard ratio = 0.44, 95%CI: 0.09-2.11, P = 0.31). Likewise, the incidences and risks of secondary outcomes, including septic shock, acute respiratory distress syndrome, or acute organ (kidney, liver, and cardiac) injuries, were also comparable between the DPP4i and non-DPP4i groups. The performance of DPP4i agents in achieving glucose control (e.g., the median level of fasting blood glucose and random blood glucose) and inflammatory regulation was approximately equivalent in the DPP4i and non-DPP4i groups. Furthermore, we did not observe substantial side effects such as uncontrolled glycemia or acidosis due to DPP4i application relative to the use of non-DPP4i agents in the study cohort.

CONCLUSION

Our findings demonstrated that DPP4i use is not significantly associated with poor outcomes of COVID-19 or other adverse effects of anti-diabetic treatment. The data support the continuation of DPP4i agents for diabetes management in the setting of COVID-19.

Nutrition Management in Older Adults with Diabetes: A Review on the Importance of Shifting Prevention Strategies from Metabolic Syndrome to Frailty

The increasing prevalence of older adults with diabetes has become a major social burden. Diabetes, frailty, and cognitive dysfunction are closely related to the mechanisms of aging. Insulin resistance, arteriosclerosis, chronic inflammation, oxidative stress, and mitochondrial dysfunction may be common mechanisms shared by frailty and cognitive impairment. Hyperglycemia, hypoglycemia, obesity, vascular factors, physical inactivity, and malnutrition are important risk factors for cognitive impairment and frailty in older adults with diabetes. The impact of nutrients on health outcomes varies with age; thus, shifting diet therapy strategies from the treatment of obesity/metabolic syndrome to frailty prevention may be necessary in patients with diabetes who are over 75 years of age, have frailty or sarcopenia, and experience malnutrition. For the prevention of frailty, optimal energy intake, sufficient protein and vitamin intake, and healthy dietary patterns should be recommended. The treatment of diabetes after middle age should include the awareness of proper glycemic control aimed at extending healthy life expectancy with proper nutrition, exercise, and social connectivity. Nutritional therapy in combination with exercise, optimal glycemic and metabolic control, and social participation/support for frailty prevention can extend healthy life expectancy and maintain quality of life in older adults with diabetes mellitus.

The Safety and Efficacy of Second-Generation Basal Insulin Analogues in Adults with Type 2 Diabetes at Risk of Hypoglycemia and Use in Other Special Populations: A Narrative Review

Hypoglycemia is a major barrier impeding glycemic control in persons with type 2 diabetes mellitus and creates a substantial burden on the healthcare system. Certain populations that require special attention, such as older adults and individuals with renal impairment, a longer duration of diabetes or those who have experienced prior hypoglycemia, may be at a higher risk of hypoglycemia, particularly with insulin treatment. Second-generation basal insulin analogues (insulin glargine 300 U/mL and degludec) have demonstrated reductions in hypoglycemia compared with insulin glargine 100 U/mL although evidence of this benefit across specific populations is less clear. In this review we summarize the literature with respect to the efficacy and safety data for second-generation basal insulin analogues in adults with type 2 diabetes mellitus who are at risk of hypoglycemia or who require special attention. Randomized controlled trials, meta-analyses and real-world evidence demonstrate that the use of second-generation basal insulin analogues is associated with less hypoglycemia compared with insulin glargine 100 U/mL without compromising glycated hemoglobin control. A reduced risk of hypoglycemia with second-generation basal insulin analogues was evident in older adults and in individuals with obesity, renal impairment, a history of cardiovascular disease or a long duration of insulin use. Further studies are needed in other populations, including those with more severe renal impairment or hepatic dysfunction, the hospitalized population and those with cognitive impairment. Overall, less hypoglycemia associated with second-generation basal insulin analogues may help reduce barriers for insulin use, improve adherence and offset the costs of hypoglycemia-related healthcare resource utilization.

A Multicenter, Prospective, Observational, Open-Label Study of the Safety and Comfort of Gensulin® Delivery Device Use in a Large Cohort of Adult and Elderly Patients with Type 2 Diabetes

Insulin treatment is necessary for many patients with type 2 diabetes, and its delivery must be safe and comfortable. This study evaluated patients' safety and comfort when using a Gensulin® delivery device, GensuPen (Bioton), a reusable insulin pen device for injecting Gensulin® insulin among adult and elderly patients with type 2 diabetes. This was a 4-week multicenter, prospective, observational, open-label study in patients with diabetes mellitus type 2 who have recently started using a GensuPen. Overall, 10,309 patients (mean age: 63 ± 12.0 years; 47.9% female) were analyzed in this study. Of these, 2.5% had used an insulin delivery device before, and for 97.5%, GensuPen was the first delivery device they had used. Most (87.8%) of the patients rated the GensuPen as very good in setting the dose, 92.0% in confirmation of successful insulin administration, 80.9% in trigger location, and 75.0% in force needed for injection. The overall safety of the GensuPen use was high since severe hypoglycemia occurred only in 0.2% of the studied patients. There were 0.6% adverse events, none of which were serious. This real-life observation data shows that the GensuPen was well accepted and safe in this large patient population of adult and elderly patients with type 2 diabetes.

Positioning sulphonylureas in a modern treatment algorithm for patients with type 2 diabetes: Expert opinion from a European consensus panel

The large number of pharmacological agents available to treat type 2 diabetes (T2D) makes choosing the optimal drug for any given patient a complex task. Because newer agents offer several advantages, whether and when sulphonylureas (SUs) should still be used to treat T2D is controversial. Published treatment guidelines and recommendations should govern the general approach to diabetes management. However, expert opinions can aid in better understanding local practices and in formulating individual choices. The current consensus paper aims to provide additional guidance on the use of SUs in T2D. We summarize current local treatment guidelines in European countries, showing that SUs are still widely proposed as second-line treatment after metformin and are often ranked at the same level as newer glucose-lowering medications. Strong evidence now shows that sodium-glucose co-transporter-2 inhibitors (SGLT-2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) are associated with low hypoglycaemia risk, promote weight loss, and exert a positive impact on vascular, cardiac and renal endpoints. Thus, using SUs in place of SGLT-2is and GLP-1RAs may deprive patients of key advantages and potentially important cardiorenal benefits. In subjects with ascertained cardiovascular disease or at very high cardiovascular risk, SGLT-2is and/or GLP-1RAs should be used as part of diabetes management, in the absence of contraindications. Routine utilization of SUs as second-line agents continues to be acceptable in resource-constrained settings.

Challenges and Strategies for Managing Diabetes in the Elderly in Long-Term Care Settings

Diabetes affects a large number of patients in the long-term care (LTC) setting, and their care is often complicated because of multimorbidity, diabetes-related complications, disability, dependency on caregivers, and geriatric syndromes, including frailty and cognitive impairment. This population includes patients receiving short-term rehabilitation in skilled nursing facilities, those who are residents in LTC facilities, and those receiving palliative or end-of-life care. An individualized approach to care based on clinical complexity, diabetes trajectory, and patients' preferences and goals is required. Such patients may experience one or more transitions of care and decline in condition. They are also prone to adverse drug events, cardiovascular events, and hypoglycemia. Facility-related challenges include varying staff competencies and practitioner preferences, inconsistent interdisciplinary communication, overly complex medication regimens, and poorly implemented care transitions.

Prevalence of Diabetes Mellitus and Its Associated Factors in Bangladesh: Application of Two-level Logistic Regression Model

This study intends to explore the prevalence of diabetes mellitus (DM) and its associated factors in Bangladesh. The necessary information was extracted from Bangladesh Demographic and Health Survey (BDHS) 2011. In bivariate analysis, Chi-square test was performed to assess the association between selected covariates and diabetes status. A two-level logistic regression model with a random intercept at each of the individual and regional level was considered to identify the risk factors of DM. A total of 7,535 individuals were included in this study. From the univariate analysis, the prevalence of DM was found to be 33.3% in 50-54 age group for instance. In bivariate setup, all the selected covariates except sex of the participants were found significant for DM (p < 0.05). According to the two-level logistic regression model, the chance of occurring DM increases as age of the participants' increases. It was observed that female participants were more likely to have DM. The occurrence of DM was 62% higher for higher educated participants, 42% higher for the individuals who came from rich family and 63% higher for the individuals having hypertension. The chance of developing diabetes among overweighed people was almost double. However, the individuals engaged in physical work had less chance to have DM. This study calls for greater attention of government and other concerned entities to come up with appropriate policy interventions to lower the risk of DM.

The Lived Experience of Older Adults With Type 2 Diabetes Mellitus and Diabetes-Related Distress

An older, more diverse population and longer lifespans are major contributors to the anticipated tripling of diabetes prevalence by 2050. Diabetes-related distress affects up to 40% of people with diabetes and may be a higher risk for older adults due to greater prevalence of comorbidities. The objective of the current phenomenological study was to describe how diabetes-related distress might be uniquely experienced by older adults (age ≥65) with type 2 diabetes mellitus (T2DM). Interpretive phenomenology guided the research design and analysis. Everyday life experiences of living with T2DM and elevated diabetes distress were investigated with interpretive interviews. The most prevalent lived experiences were strained relationships with health care providers, guilt, fear, loneliness, and forgetfulness. These experiences created challenges in managing diabetes and increased diabetes-related distress. Improving knowledge regarding the lived experience of older adults with diabetes-related distress may allow health care providers to tailor treatment to this population, thus improving outcomes. [Journal of Gerontological Nursing, 46(3), 37-44.].

Prevalence and associated factors of hospitalization for dysglycemia among elderly type 2 diabetes patients: A nationwide study

BACKGROUND

The prevalence of older individuals with type 2 diabetes mellitus (T2DM) is increasing due to the aging population and improved medical care. These patients are very susceptible to disease and treatment-related hospitalizations, resulting in higher health care costs, morbidity, and decreased quality of life. However, data of treatment-related complications, especially dysglycemia-related hospitalizations, are lacking.

AIM

To assess the prevalence and associated factors for dysglycemia-related hospitalizations among elderly diabetic patients in Thailand using nationwide patient sample.

METHODS

T2DM patients aged ≥ 65 years who received medical care at public hospitals in Thailand in the year 2014 were included. The prevalence of hospitalization due to dysglycemia within one year was examined. Multivariable logistic regression was performed to assess the independent factors associated with hospitalization due to hypoglycemia and hyperglycemia.

RESULTS

A total of 11404 elderly T2DM patients were enrolled in this study. The mean age was 72.9 ± 5.5 years. The prevalence of hospital admissions due to diabetic ketoacidosis, hyperosmolar hyperglycemic state, hyperglycemic dehydration syndrome, and hypoglycemia among elderly T2DM patients in the year 2014 was 0.1%, 0.1%, 1.7% and 3.1%, respectively. Increased hospitalization due to hypoglycemia was associated with older age, female sex, had hypertension, dementia, lower body mass index, elevated hemoglobin A1C (HbA1C), decreased kidney function, insulin use. Increased hospitalization due to hyperglycemia was associated with dementia, depression, lower body mass index, elevated HbA1C, and insulin use.

CONCLUSION

The prevalence of dysglycemia-related hospitalization in elderly T2DM patients in Thailand was 4.9%. Close monitoring of blood glucose should be provided in high-risk patients for prevention and early detection for these complications.