Varying insulin use in older hospitalized patients with diabetes

Management of Inpatient Hyperglycemia and Diabetes in Older Adults

Diabetes is one of the world's fastest growing health challenges. Insulin therapy remains a useful regimen for many elderly patients, such as those with moderate to severe hyperglycemia, type 1 diabetes, hyperglycemic emergencies, and those who fail to maintain glucose control on non-insulin agents alone. Recent clinical trials have shown that several non-insulin agents as monotherapy, or in combination with low doses of basal insulin, have comparable efficacy and potential safety advantages to complex insulin therapy regimens. Determining the most appropriate diabetes management plan for older hospitalized patients requires consideration of many factors to prevent poor outcomes related to dysglycemia.

Inpatient Management of T2DM and Hyperglycemia in Older Adults

PURPOSE OF REVIEW

This review aims to provide a summary of the evaluation and treatment of older adults (≥ 65 years) with type 2 diabetes and/or hyperglycemia in the hospital.

RECENT FINDINGS

Caring for these older adults requires special considerations. Diabetes is a risk factor for hospitalization and hyperglycemia in the hospital is associated with increased complications and mortality. Treatment plans for hospitalized older adults with diabetes should include a comprehensive geriatric assessment. This team-based approach aims to develop an individualized care plan, with consideration of the patients' personal goals, comorbidities, functional status, life expectancy, and hypoglycemia risk. Studies from hospitalized middle age and older adults with hyperglycemia can help guide diabetes treatment goals and management in older adults. Further studies, examining both glucose targets and care management assessments and treatment plan specifically targeting older adults in the hospital setting, are needed.

Treatment of type 2 diabetes mellitus in the older adult: a review

OBJECTIVE

This review summarizes the particular challenges of diabetes in older individuals and the evidence base guiding the selection of treatment targets and strategies in this population.

METHODS

An in-depth literature search was conducted to identify the evidence base from randomized, controlled, and population-based epidemiological studies, as well as guidelines derived from expert opinion.

RESULTS

Older patients are a highly heterogeneous population with respect to the pathogenesis and course of diabetes and, as a group, manifest significant comorbidities that impact treatment goals and strategies. There is a lack of consensus regarding "optimal" glucose targets in older patients with diabetes. Hypoglycemia is more common in the older patient, contributes to increased morbidity and reduced quality of life, and limits treatment in many cases. Duration of diabetes, comorbidities, life expectancy, and functional status are other important factors to consider when identifying appropriate glycemic goals and choosing an antihyperglycemic agent for older patients with type 2 diabetes mellitus (T2DM).

CONCLUSION

Current, limited treatment recommendations in older patients with T2DM are based on expert opinion due to the general lack of evidence from randomized controlled trials. This underscores the importance of individualizing pharmacologic therapy in these patients with a focus on the risk-to-benefit ratio. Additional trials in older patients are needed to assess drug safety, efficacy, and dosing.

Elderly patients with type 2 diabetes mellitus-the need for high-quality, inpatient diabetes care

Elderly patients (aged > 70 years) with diabetes are at high risk of -hospitalization. We provide a detailed commentary about recent international clinical guidelines and a consensus statement devoted to elderly patients with type 2 diabetes mellitus in the context of hospitalization. In emergency departments, the 4 medication agents associated with the greatest number of patient adverse drug events are warfarin, oral glucose-lowering medications, insulin, and antiplatelet agents, all of which are commonly prescribed in older patients with diabetes. Comprehensive gerontological assessment, including review and, if indicated, discontinuation of all potentially unsafe or inappropriate patient medications should be done upstream to reduce the likelihood of adverse drugs events. Severe infections and ischemic heart disease are also frequent causes of acute admission into hospital in patients aged > 75 years. These patients are also likely to be malnourished and nutritional status should be monitored. Nutritional support, combined with specific products to avoid uncontrolled hyperglycemia must be implemented in patients at risk of malnutrition. Early exercise prescription may help patients maintain physical function and prevent the risk of falling. Clinical guidelines should be applied to achieve safe and effective patient target glucose levels. Insulin should be used earlier for its anabolic properties and patients closely monitored to reduce the risk of hypoglycemia and excessive hyperglycemia. The discharge plan needs to address full medical and social needs along with suitable follow-up to ensure a high level of patient safety.

Incretin therapies in the management of elderly patients with type 2 diabetes mellitus

Aging is characterized by a progressive increase in the prevalence of type 2 diabetes mellitus (T2DM), which approaches 20% by age 70 years. Older patients with T2DM are a very heterogeneous group with multiple comorbidities, an increased risk of hypoglycemia, and a greater susceptibility to adverse effects of antihyperglycemic drugs, making treatment of T2DM in this population challenging. The risk of severe hypoglycemia likely represents the greatest barrier to T2DM care in the elderly. Although recent guidelines recommend more flexibility in treating this population with individualized targets, inadequate glycemic control is still closely linked to poor outcome in elderly patients. Incretins (glucose-dependent insulinotropic polypeptide [GIP] and glucagon-like peptide-1 [GLP-1]) are hormones released post-meal from intestinal endocrine cells that stimulate insulin secretion and suppress postprandial glucagon secretion in a glucose-dependent manner. "Incretin therapies," comprising the injectable GLP-1 analogs and oral dipeptidyl peptidase-4 (DPP-4) inhibitors, are promising new therapies for use in older patients because of their consistent efficacy and low risk of hypoglycemia. However, data with these new agents are still scarce in this population, which has not been particularly well represented in clinical trials, highlighting the need for additional specific studies. The objective of this article is to provide an overview of the available data and potential role of these novel incretin therapies in managing T2DM in the elderly. With the exception of the DPP-4 inhibitor vildagliptin, there is no published trial to date dedicated to this population, although a few studies are currently ongoing. Therefore, available data from elderly subgroups of individual studies were also reviewed when available, as well as pooled analyses by age subgroups across clinical programs conducted with incretin therapies.