[Treatment of type 2 diabetes in the elderly]

Trends in glycemic control, cardiovascular risk factors and chronic complications of type 2 diabetes, 2012-2016, in a healthcare area of Barcelona

AIMS

This study aimed to analyse the evolution of the metabolic control, cardiovascular risk factors and chronic complications in a Type 2 Diabetes (T2D) population in a healthcare area of Barcelona.

METHODS

We carried out a comparative study of T2D patients (20.457) between 2012 and 2016 (data recorded in the "Electronic Clinical-Station in Primary Care") concerning: age, gender, body mass index (BMI), arterial blood pressure (BP), HbA1c, LDL-Cholesterol, smoking, heart failure (HF), micro and macrovascular complications.

RESULTS

Average HbA1c was 6.9 % in 2012 and 7 % in 2016 (Non significant differences)(NS). In 2012, 57.9 % of patients presented proper glycaemic control, 42.8 % LDL-Cholesterol < 100 mg/dL and 76.9 % BP < 140/90 while in 2016 it was 61.2 % (NS), 59.2 % (p = 0.001) and 82.9 % (p = 0.016) respectively. No changes were found in BMI or active smoking. Significant increases were found in the prevalence of microvascular complications, HF and peripheral vasculopathy (PV). Patients with vascular diseases (PVD) and adequate metabolic control increased from 57.5 % to 62.7 % (p = 0.006). Albuminuria > 30 mg/g were more frequent among PVD.

CONCLUSIONS

Between 2012 and 2016 it was observed that, amongst our study population, glycaemic control was steady and cholesterol and BP levels were improved, while there was a significant increase of diabetic complications, HF and PV.

Optimizing drug therapy in frail patients with type 2 diabetes mellitus

BACKGROUND

Type 2 diabetes mellitus (T2DM) is closely linked with ageing. In frail diabetic patients, the risks of intensive antidiabetic therapy outweigh the potential benefits.

AIMS

To study the prevalence of T2DM in frail elderly patients, to identify inappropriate prescription (IP) of antidiabetic drugs and to study the relationship between patients' frailty index (FI) with polypharmacy and IP.

METHODS

This was a prospective, descriptive, observational study of elderly patients. Each patient's antidiabetic treatment was analysed by applying the patient-centred prescription model (PCP), which centres therapeutic decisions on the patient's global assessment and individual therapeutic goal.

RESULTS

210 patients with T2DM were included (25.15% prevalence). They were characterised by high multimorbidity and frailty. 93.3% presented polypharmacy and 51% excessive polypharmacy. IP was identified in 66.2% of patients. A statistically significant relationship was found between the progression in FI degree and IP prevalence (p < 0.05. During the admission, drug therapy regimens were modified in 97.1% of cases with IP (n = 136).

DISCUSSION

These results suggest that in clinical practice T2DM treatment is not individualised, but rather is based on the same general recommendations for the population as a whole.

CONCLUSIONS

There is a high prevalence of T2DM in the elderly. As the frailty of patients increases, so does the prevalence of IP. The application of PCP model enables drug therapy optimization in frail patients according to their main therapeutic goal, and contributes to provide clinical evidences on the applicability of a set of knowledge areas from the theoretical framework to the daily clinical practice.

Prescription patterns of antihyperglycemic drugs in elderly patients in Spain: A national cross-sectional study

BACKGROUND AND OBJECTIVE

Elderly patients with type 2 diabetes represent a growing and heterogeneous group of subjects where treatment targets and antihyperglycemic drugs prescriptions should be tailored according to coexisting illnesses, functional and social domains.

METHODS

We carried-out a national cross-sectional study (from February 2014 to December 2014) to assess prescription patterns and treatment inadequacy in patients with type 2 diabetes older than 65 years with at least 6 months of treatment with antihyperglycemic drugs.

RESULTS

We included a total of 4,917 patients cared by 2,100 family physicians and 450 specialists. Diabetes prescriptions were monotherapy (21.2%), dual therapy (58.1%) and triple therapy (20.6%). The most common prescription patterns were metformin in monotherapy (66.5%), metformin plus DPP4 inhibitors in dual therapy (77.3%) and, in triple therapy, oral drugs (45.5%) and oral drugs plus insulin (45.8%). A total of 1,272 (25.9%) patients were at risk of serious hypoglycemia, 643 of them due to treatment with secretagogues (25%) or treatment with human insulin types (25.6%).

CONCLUSIONS

Elderly patients with type 2 diabetes often receive antihyperglycemic therapy with higher risk of hypoglycemia. Substitution of secretagogues and human insulin therapy for safer medication could significantly reduce the adverse effects of diabetes treatment in this population.

[Deprescribing to increase people health or when deprescribing could be the best pill]

The increasing longevity of the population, the increase in morbidity and the consumption of medications have caused that polypharmacy is a priority health problem due to its consequences: increase of adverse effects, pharmacological interactions and favor the functional deterioration of the patient. The clinical situation of the patients changes over time and it is necessary to adjust the medication in each stage, assessing the fragility, the level of dependence and the functional deterioration. Deprescription is complex and requires an adequate clinical and pharmacological formation. In Primary Care lies the greater knowledge of the patient and their environment, and in a shared way with the patient and caregivers, it is necessary to assess which drugs to maintain and which ones to withdraw from a clinical, ethical and social perspective. There are tools to help deprescription that can be useful for Primary Care to facilitate this process and that are detailed in this article.

[Treatment of type 2 diabetes mellitus in elderly patients]

The prevalence of type 2 diabetes mellitus (DM2) increases markedly with age. Antidiabetic treatment and the objectives of glycaemic control in elderly patients with DM2 should be individualised according to their biopsychosocial characteristics. In elderly patients for whom the benefits of intensive antidiabetic treatment are limited, the basic objectives should be to improve the quality of life, preserve functionality and avoid adverse effects, especially hypoglycaemia. Treatment of DM2 in the elderly was the subject of a consensus document published in 2012 and endorsed by several Spanish scientific societies. Since then, new therapeutic groups and evidence have emerged that warrant an update to this consensus document. The present document focuses on the therapeutic aspects of DM2 in elderly patients, understood as being older than 75 years or frail.

Treatment of type 2 diabetes mellitus in elderly patients

The prevalence of type 2 diabetes mellitus (DM2) increases markedly with age. Antidiabetic treatment and the objectives of glycaemic control in elderly patients with DM2 should be individualised according to their biopsychosocial characteristics. In elderly patients for whom the benefits of intensive antidiabetic treatment are limited, the basic objectives should be to improve the quality of life, preserve functionality and avoid adverse effects, especially hypoglycaemia. Treatment of DM2 in the elderly was the subject of a consensus document published in 2012 and endorsed by several Spanish scientific societies. Since then, new therapeutic groups and evidence have emerged that warrant an update to this consensus document. The present document focuses on the therapeutic aspects of DM2 in elderly patients, understood as being older than 75 years or frail.

Glycaemic control of elderly patients with type 2 diabetes mellitus in Spain (2015) and its relationship with functional capacity and comorbidity. The Escadiane study

OBJECTIVES

To understand the state of glycaemic control of elderly patients with type 2 diabetes mellitus in Spain and its relationship with functional capacity and comorbidity.

METHODS

Cross-sectional, observational, multicentre national study on patients with diabetes mellitus aged 65 years or older. The study analysed demographic and anthropometric variables, cardiovascular risk factors, clinical and laboratory data, associated comorbidity and treatments. We analysed the functional capacity using the Barthel index and the comorbidity with Charlson index.

RESULTS

The study included 939 patients with a mean age of 76.4±6.7 years. The mean glycated haemoglobin (HbA1c) level was 7.0%±1.2%, and the mean basal blood glucose level was 137±39.6mg/dL. The HbA1c level showed statistically significant differences depending on the degree of disability. In the patients who were totally, severely, moderately or slightly dependent or who were independent, the mean HbA1c levels were 7.0%, 7.9%, 7.4% and 7.0%, respectively (P<.028). HbA1c levels were 7.3%, 7.1% and 6.9% in the patients with very high, high and medium comorbidity, respectively (P<.001).

CONCLUSIONS

Mean HbA1c levels in elderly patients with type 2 diabetes analysed in Spain are below those recommended by the main clinical practice guidelines. The levels are higher in patients who have more functional disability and a higher level of comorbidity.

Efficacy and safety of metformin in the management of type 2 diabetes mellitus in older adults: a systematic review for the development of recommendations to reduce potentially inappropriate prescribing

Background

Metformin is usually prescribed as first line therapy for type 2 diabetes mellitus (DM2). However, the benefits and risks of metformin may be different for older people. This systematic review examined the available evidence on the safety and efficacy of metformin in the management of DM2 in older adults. The findings were used to develop recommendations for the electronic decision support tool of the European project PRIMA-eDS.

Methods

The systematic review followed a staged approach, initially searching for systematic reviews and meta-analyses first, and then individual studies when prior searches were inconclusive. The target population was older people (≥65 years old) with DM2. Studies were included if they reported safety or efficacy outcomes with metformin (alone or in combination) for the management of DM2 compared to placebo, usual or no treatment, or other antidiabetics. Using the evidence identified, recommendations were developed using GRADE methodology.

Results

Fifteen studies were included (4 intervention and 11 observational studies). In ten studies at least 80% of participants were 65 years or older and 5 studies reported subgroup analyses by age. Comorbidities were reported by 9 studies, cognitive status was reported by 4 studies and functional status by 1 study. In general, metformin showed similar or better safety and efficacy than other specific or non-specific active treatments. However, these findings were mainly based on retrospective observational studies. Four recommendations were developed suggesting to discontinue the use of metformin for the management of DM2 in older adults with risk factors such as age > 80, gastrointestinal complaints during the last year and/or GFR ≤60 ml/min.

Conclusions

On the evidence available, the safety and efficacy profiles of metformin appear to be better, and certainly no worse, than other treatments for the management of DM2 in older adults. However, the quality and quantity of the evidence is low, with scarce data on adverse events such as gastrointestinal complaints or renal failure. Further studies are needed to more reliably assess the benefits and risks of metformin in very old (>80), cognitively and functionally impaired older people.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-017-0574-5) contains supplementary material, which is available to authorized users.

Inadequate Glycaemic Control and Therapeutic Management of Adults over 65 Years Old with Type 2 Diabetes Mellitus in Spain

OBJECTIVES

The glycaemic goals for older patients with type 2 diabetes mellitus (DM) are recommended to avoid an HbA1c levels <7%. The purpose of this study was to analyse the glycaemic control and therapeutic management of older adults (≥65 years) with type 2 DM.

DESIGN

Pooled analysis of patients enrolled in three Spanish cross-sectional epidemiological studies.

SETTING

The study was conducted between 2009 and 2011 by primary care or specialist physicians.

PARTICIPANTS

A total of 7,269 patients aged ≥65 years with type 2 DM.

MEASUREMENTS

Sociodemographic, medical history, lifestyle habits, biochemical laboratory parameters, comorbidities, type 2 DM complications, and pharmacological treatment data collected from medical records.

RESULTS

In total, data from 7,269 patients were analysed (mean age 73.4 years old; 48.4% male). A total of 10.9% of patients had HbA1c levels ≥8.5% and 43.2% <7%. The most common comorbidities were hypertension (82.0%) and dyslipidaemia (76.6%). The microvascular complications were mainly diabetic nephropathy (23.6%) and retinopathy (19.3%). Oral antidiabetic drugs (OADs) were taken by 70.5% of patients (sulphonylureas 65.3%), 4.1% were taking insulin alone and 25.4% took both insulin and an OAD. Half of the patients (51.0%) were taking a combination of OADs.

CONCLUSION

In conclusion, more than half of older patients with type 2 DM had unsatisfactory management: approximately one in ten had inadequate glycaemic control (HbA1c ≥8.5%) despite hypoglycaemic drugs and four in ten were potentially overtreated (HbA1c <7%).

Update on the treatment of type 2 diabetes mellitus

To achieve good metabolic control in diabetes and keep long term, a combination of changes in lifestyle and pharmacological treatment is necessary. Achieving near-normal glycated hemoglobin significantly, decreases risk of macrovascular and microvascular complications. At present there are different treatments, both oral and injectable, available for the treatment of type 2 diabetes mellitus (T2DM). Treatment algorithms designed to reduce the development or progression of the complications of diabetes emphasizes the need for good glycaemic control. The aim of this review is to perform an update on the benefits and limitations of different drugs, both current and future, for the treatment of T2DM. Initial intervention should focus on lifestyle changes. Moreover, changes in lifestyle have proven to be beneficial, but for many patients is a complication keep long term. Physicians should be familiar with the different types of existing drugs for the treatment of diabetes and select the most effective, safe and better tolerated by patients. Metformin remains the first choice of treatment for most patients. Other alternative or second-line treatment options should be individualized depending on the characteristics of each patient. This article reviews the treatments available for patients with T2DM, with an emphasis on agents introduced within the last decade.

[Non-cardiac aspects of aortic stenosis in the elderly: A review]

Aortic stenosis (AS) is the most frequent valve disease in the elderly population Treatment is valve replacement either by open surgery, or in the case of patients at high surgical risk, by TAVI (Transcatheter Aortic Valve Implantation). However, almost 40% of patients who have undergone TAVI show poor health outcomes, either due to death or because their clinical status does not improved. This review examines the non-cardiac aspects of patients with AS, which may help answer three key questions in order to evaluate this condition pre-surgically: 1) Are the symptoms presented by the patient exclusively explained by the AS, or are there other factors or comorbidities that could justify or increase them?, 2) What possibilities for improvement of health status and quality of life has the patient after the valve replacement?, and 3) How can we reduce the risk of a futile valve replacement?

[Diabetes mellitus and cardiovascular risk: Working group recommendations of Diabetes and Cardiovascular Disease of the Spanish Society of Diabetes (SED, 2015)]

The present paper updates the Clinical Practice Recommendations for the management of cardiovascular risk factors (CVRF) in diabetes mellitus. This is a medical consensus agreed by an independent panel of experts from the Spanish Society of Diabetes (SED). Several consensuses have been proposed by scientific and medical Societies to achieve clinical goals. However, the risk score for general population may lack sensitivity for individual assessment or for particular groups at risk, such as diabetics. Traditional risk factors together with non-traditional factors are reviewed throughout this paper. Intervention strategies for managing CVRF in the diabetic patient are reviewed in detail: balanced food intake, weight reduction, physical exercise, smoking cessation, reduction in HbA1c, therapy for high blood pressure, obesity, lipid disorders, and platelet anti-aggregation. It is hoped that these guidelines can help clinicians in the decisions of their clinical activity. This regular update by the SED Cardiovascular Disease Group of the most relevant concepts, and of greater practical and realistic clinical interest, is presented in order to reduce CVR of diabetics.

[Chronic ischaemic heart disease in the elderly]

It is the aim of this manuscript to take into account the peculiarities and specific characteristics of elderly patients with chronic ischaemic heart disease from a multidisciplinary perspective, with the participation of the Spanish Society of Cardiology (sections of Geriatric Cardiology and Ischaemic Heart Disease/Acute Cardiovascular Care), the Spanish Society of Internal Medicine, the Spanish Society of Primary Care Physicians and the Spanish Society of Geriatrics and Gerontology. This consensus document shows that in order to adequately address these elderly patients a comprehensive assessment is needed, which includes comorbidity, frailty, functional status, polypharmacy and drug interactions. We conclude that in most patients medical treatment is the best option and that this treatment must take into account the above factors and the biological changes associated with aging.

[Differential characteristics of type 2 diabetes in the elderly. Role of dipeptidyl peptidase 4 inhibitors]

The prevalence of type 2 diabetes mellitus increases with age, reaching rates around 30% in those over 75 years. The type 2 diabetes mellitus in the elderly has different pathophysiological and clinical characteristics from those of the younger diabetic patient. Some differential aspects in this population are the lower life expectancy and the frequent comorbidity, frailty and associated disability. Avoiding hypoglycemia is a therapeutic priority, given their increased risk of severe hypoglycemia. It is a situation in which the benefits of intensive glycemic control are virtually non-existent, thus prevention of side effects of treatments becomes a priority. Therefore, the goals of glycemic control should be less stringent than in the general population (glycated hemoglobin>7%), and the drugs of choice should be those with a low risk of side effects (especially hypoglycemia) and well tolerated. Dipeptidyl peptidase 4 inhibitors (iDPP4) are particularly useful in this age group, either as a second drug added to metformin monotherapy, or as first line when metformin is contraindicated or not tolerated. In this article the evidence available on the efficacy and tolerance of different pharmacological options available in population over 70 years is reviewed.

Update in cardiology: vascular risk and cardiac rehabilitation

As in other fields, understanding of vascular risk and rehabilitation is constantly improving. The present review of recent epidemiological update shows how far we are from achieving good risk factor control: in diet and nutrition, where unhealthy and excessive societal consumption is clearly increasing the prevalence of obesity; in exercise, where it is difficult to find a balance between benefit and risk, despite systemization efforts; in smoking, where developments center on programs and policies, with the electronic cigarette seeming more like a problem than a solution; in lipids, where the transatlantic debate between guidelines is becoming a paradigm of the divergence of views in this extensively studied area; in hypertension, where a nonpharmacological alternative (renal denervation) has been undermined by the SYMPLICITY HTN-3 setback, forcing a deep reassessment; in diabetes mellitus, where the new dipeptidyl peptidase-4 and sodium-glucose cotransporter type 2 inhibitors and glucagon like peptide 1 analogues have contributed much new information and a glimpse of the future of diabetes treatment, and in cardiac rehabilitation, which continues to benefit from new information and communication technologies and where clinical benefit is not hindered by advanced diseases, such as heart failure. Our summary concludes with the update in elderly patients, whose treatment criteria are extrapolated from those of younger patients, with the present review clearly indicating that should not be the case.

Unanswered clinical questions in the management of cardiometabolic risk in the elderly: a statement of the Spanish Society of Internal Medicine

BACKGROUND

Despite the progressive increase in life expectancy and the relationship between aging with multi-morbidities and the increased use of healthcare resources, current clinical practice guidelines (CPG) on cardiometabolic risk cannot be adequately applied to elderly subjects with multiple chronic conditions. Its management frequently becomes complicated by both, an excessive use of medications that may lead to overtreatment, drug interactions and increased toxicity, and errors in dosage and non-compliance. Concerned by this gap, the Spanish Society of Internal Medicine created a group of independent experts on cardiometabolic risk who discussed what they considered to be unanswered questions in the management of elderly patients.

DISCUSSION

Current guidelines do not specifically address the problem of elderly with multiple chronic conditions. For this reason, the combined use of the limited available evidence, clinical experience and common sense, could all help us to address this unmet need. In very old people, life expectancy and functionality are the most important factors for guiding potential treatments. Their higher propensity to develop serious adverse events and their shorter lifespan could prevent them from obtaining the potential benefits of the interventions administered.

SUMMARY

In this document, experts on cardiometabolic risk factors have established a number of consensual recommendations that have taken into account international guidelines and clinical experience, and have also considered the more effective use of healthcare resources. This document is intended to provide general recommendations for clinicians and to promote the effective use of procedures and medications.

Efficacy of treatment for hyperglycemic crisis in elderly diabetic patients in a day hospital

Background

The purpose of this prospective cohort study was to compare the costs of day hospital (DH) care for hyperglycemic crisis in elderly diabetic patients with those of conventional hospitalization (CH). Secondary objectives were to compare these two clinical scenarios in terms of glycemic control, number of emergency and outpatient visits, readmissions, hypoglycemic episodes, and nosocomial morbidity.

Methods

The study population comprised diabetic patients aged >74 years consecutively admitted to a tertiary teaching hospital in Spain for hyperglycemic crisis (sustained hyperglycemia [>300 mg/dL] for at least 3 days with or without ketosis). The patients were assigned to DH or CH care according to time of admission and were followed for 6 months after discharge. Exclusion criteria were ketoacidosis, hyperosmolar crisis, hemodynamic instability, severe intercurrent illness, social deprivation, or Katz index >D.

Results

Sixty-four diabetic patients on DH care and 36 on CH care were included, with no differences in baseline characteristics. The average cost per patient was 1,345.1±793.6 € in the DH group and 2,212.4±982.5 € in the CH group (P<0.001). There were no differences in number of subjects with mild hypoglycemia during follow-up (45.3% DH versus 33.3% CH, P=0.24), nor in the percentage of patients achieving a glycated hemoglobin (HbA_1c) <8% (67.2% DH versus 58.3% CH, P=0.375). Readmissions for hyperglycemic crisis and pressure ulcer rates were significantly higher in the CH group.

Conclusion

DH care for hyperglycemic crises is more cost-effective than CH care, with a net saving of 1,418.4 € per case, lower number of readmissions and pressure ulcer rates, and similar short-term glycemic control and hypoglycemia rates.

Type 2 diabetes mellitus in elderly institutionalized patients

A 93-year-old woman is admitted to a conventional hospital ward for an acute respiratory infection. The patient has type 2 diabetes mellitus of approximately 15 years evolution and has no other associated comorbidities, except for progressive dependence due to senescence and a previous hospitalization for pneumonia 6 months ago. She is currently in an assisted-living residence. A recent laboratory test revealed an HbA1c level of 7.8%, with a serum creatinine level of 1.3mg/dl (MDRD, 45ml/min). Her standard treatment consists of 5mg of glibenclamide a day and 850mg of metformin every 12hours. What regimen should we follow once she is hospitalized? Does she require any change in her treatment at discharge?

Assessment of an educational intervention in the management of non-critical inpatient glycemic control

In hospitalized diabetic patients, the recommended insulin therapy is basal bolus plus correction-dose regimen instead of sliding-scale insulin. The purpose of this study was to evaluate the effect of the implementation of a new protocol based on basal bolus therapy on managing diabetes in a university hospital setting. We performed a cross-sectional study before and 12 months after a 4-month intervention period to implement a basal bolus regimen in hospitalized patients. Non-critical patients admitted into the hospital for at least 72 h were included. Changes in prescribing habits, glucose control and incidence of hypoglycemia were evaluated. An increase in the use of the new protocol and a decrease in sliding scale were observed after the intervention. In the pre-intervention group, a total of 59.2% glucose readings were between 70 and 180 mg/dL versus 57.1% after the intervention, without observing statistical differences. Significant reductions in hypoglycemia between pre- and post-intervention (13.04 vs. 4.08%, p = 0.0215) were observed. The percentage of hospitalized diabetic patients who had HbA1c was 10.43 and 4.08% in pre- and post-intervention phases, respectively. The protocol showed beneficial outcomes in terms of fewer hypoglycemia episodes and reflected a change in prescription habits, but it did not improve glycemic control. Furthermore, the percentage of patients who had an HbA1c test during their hospitalization remained very low after the intervention. This fact may seriously limit the correct management of hyperglycemia after the hospital discharge.

[Treatment of type 2 diabetes mellitus in patients with chronic kidney disease. Grupo de Trabajo para el Documento de Consenso sobre el tratamiento de la diabetes tipo 2 en el paciente con enfermedad renal crónica]

Chronic kidney disease (CKD) and type 2 diabetes mellitus (T2DM) are highly prevalent chronic diseases, which represent an important public health problem and require a multidisciplinary management. T2DM is the main cause of CKD and it also causes a significant comorbidity with regard to non-diabetic nephropathy. Patients with diabetes and kidney disease represent a special risk group as they have higher morbi-mortality as well as higher risk of hypoglycemia than diabetic individuals with a normal kidney function. Treatment of T2DM in patients with CKD is controversial because of the scarcity of available evidence. The current consensus report aims to ease the appropriate selection and dosage of antidiabetic treatments as well as the establishment of safety objectives of glycemic control in patients with CKD.

Hypoglycaemia begets hypoglycaemia

Drug-induced (insulin/insulin secretagogue) hypoglycaemia is the most common cause of hypoglycaemia particularly in the elderly. It is estimated that hypoglycaemia of any severity occurs annually in 5-20% of patients taking antihyperglycaemic agents. Although these hypoglycaemic episodes are rarely fatal, they can be associated with serious clinical sequelae. The half-life for most sulfonylurea medications is 14-16 h; they can cause severe, prolonged hypoglycaemia. It is important to recognise, prevent and treat hypoglycaemic episodes secondary to the use of antihyperglycaemic agents. Patient education has become focused on minimising hyperglycaemia but emphasis must be placed on minimising even minor subclinical hypoglycaemia because it will contribute to a vicious cycle of hypoglycaemia begetting hypoglycaemia. Ten per cent dextrose is recommended for the reversal of all hypoglycaemic episodes rather than the conventional 50% dextrose. Octreotide can be an option for recurrent and relapsing hypoglycaemia in an acute setting.