Diabetes in the elderly

Continuous glucose monitoring for the routine care of type 2 diabetes mellitus

Although continuous glucose monitoring (CGM) devices are now considered the standard of care for people with type 1 diabetes mellitus, the uptake among people with type 2 diabetes mellitus (T2DM) has been slower and is focused on those receiving intensive insulin therapy. However, increasing evidence now supports the inclusion of CGM in the routine care of people with T2DM who are on basal insulin-only regimens or are managed with other medications. Expanding CGM to these groups could minimize hypoglycaemia while allowing efficient adaptation and escalation of therapies. Increasing evidence from randomized controlled trials and observational studies indicates that CGM is of clinical value in people with T2DM on non-intensive treatment regimens. If further studies confirm this finding, CGM could soon become a part of routine care for T2DM. In this Perspective we explore the potential benefits of widening the application of CGM in T2DM, along with the challenges that must be overcome for the evidence-based benefits of this technology to be delivered for all people with T2DM.

Expanding the Role of Continuous Glucose Monitoring in Modern Diabetes Care Beyond Type 1 Disease

Application of continuous glucose monitoring (CGM) has moved diabetes care from a reactive to a proactive process, in which a person with diabetes can prevent episodes of hypoglycemia or hyperglycemia, rather than taking action only once low and high glucose are detected. Consequently, CGM devices are now seen as the standard of care for people with type 1 diabetes mellitus (T1DM). Evidence now supports the use of CGM in people with type 2 diabetes mellitus (T2DM) on any treatment regimen, not just for those on insulin therapy. Expanding the application of CGM to include all people with T1DM or T2DM can support effective intensification of therapies to reduce glucose exposure and lower the risk of complications and hospital admissions, which are associated with high healthcare costs. All of this can be achieved while minimizing the risk of hypoglycemia and improving quality of life for people with diabetes. Wider application of CGM can also bring considerable benefits for women with diabetes during pregnancy and their children, as well as providing support for acute care of hospital inpatients who experience the adverse effects of hyperglycemia following admission and surgical procedures, as a consequence of treatment-related insulin resistance or reduced insulin secretion. By tailoring the application of CGM for daily or intermittent use, depending on the patient profile and their needs, one can ensure the cost-effectiveness of CGM in each setting. In this article we discuss the evidence-based benefits of expanding the use of CGM technology to include all people with diabetes, along with a diverse population of people with non-diabetic glycemic dysregulation.

Reduced acute diabetes events after FreeStyle Libre® system initiation in people 65 years or older with type 2 diabetes on intensive insulin therapy in France

Background and aims Older people with type 2 diabetes (T2DM) on insulin are at increased risk of hypoglycemia and associated morbidity. Management of T2DM in older people must optimize glycemic control while minimizing risks for hypoglycemia and diabetic ketoacidosis (DKA). In France, the FreeStyle Libre® system (FSL) has been reimbursed since June 2017 for T2DM on intensive insulin therapy. We assessed the impact of starting FSL on hospitalizations for acute diabetes events (ADEs) in people ≥65 years old, with T2DM on intensive insulin therapy. Materials and methods A retrospective study on the French SNDS claims database was conducted on people ≥65 years old with T2DM, treated with MDI or insulin pump and starting FSL between 01/08/2017 to 31/12/2018. The analysis covered claims data for 12 months before, and up to 24 months after FSL initiation. Hospitalizations for severe hypoglycemia (SH), DKA, comas and hyperglycemia were identified using ICD-10 codes. Results We identified 38,312 people with T2DM ≥65 years old on intensive insulin therapy initiating FSL during the selection period. Hospitalizations for ADEs were observed in 1.6% of subjects in the 12 months before FSL initiation, compared to 1.05% after 12 months and 0.96% after 24 months, a 34% and 40% reduction, driven by fewer DKA admissions after 12 months and by fewer SH admissions at 24 months. Conclusions These results indicate that FSL can reduce hospitalization for ADEs in this vulnerable older population of adults aged 65 years and older with T2DM on intensive insulin therapy, in whom optimal glycemic control must be achieved while minimizing risk of hypoglycemia and other ADEs.

Age-specific associations between the number of co-morbidities, all-cause mortality and public direct medical costs in patients with type 2 diabetes: A retrospective cohort study

AIM

To evaluate the association between the number of co-morbidities, all-cause mortality and public health system expenditure in patients with type 2 diabetes (T2D) across different age groups.

MATERIALS AND METHODS

A retrospective observational study of T2D patients using electronic health records in Hong Kong was conducted. Patients were stratified by age (< 50, 50-64, 65-79, ≥ 80 years) and the number of co-morbidities (0, 1, 2, 3, ≥ 4), defined using the Charlson Comorbidity Index and prevalent chronic diseases identified in local surveys. The association between the number of co-morbidities, all-cause mortality and direct medical costs was examined using Cox proportional hazard regression and the gamma generalized linear model with log link function.

RESULTS

A total of 262 212 T2D patients with a median follow-up of 10 years were included. Hypertension and dyslipidaemia were the most common co-morbidities in all age groups. After age stratification, cardiovascular diseases dominated the top pair of co-morbidities in the older age groups (65-79 and ≥ 80 years), while inflammatory and liver disease were predominant among younger individuals. Compared with co-morbidity-free T2D patients, the hazard ratios (95% CI) of death for patients aged younger than 50 and 80 years or older with two co-morbidities were 1.31 (1.08-1.59) and 1.25 (1.15-1.36), respectively, and increased to 3.08 (2.25-4.21) and 1.98 (1.82-2.16), respectively, as the number of co-morbidities increased to four or more. Similar trends were observed for medical costs.

CONCLUSIONS

Age-specific co-morbidity patterns were observed for patients with T2D. A greater number of co-morbidities was associated with increased mortality and healthcare costs, with stronger relationships observed among younger patients.

Assessment of Glucose Monitoring Adherence in Medicare Beneficiaries with Insulin-Treated Diabetes

Background: We investigated the potential associations between race/ethnicity and adherence to prescribed glucose monitoring in a sample of Medicare beneficiaries with diabetes and how adherence to the method used impacted diabetes-related inpatient hospitalizations and associated costs among beneficiaries with intensive insulin-treated diabetes. Methods: This 12-month retrospective analysis utilized Centers for Medicare & Medicaid Services data to identify Medicare beneficiaries who used intensive insulin therapy from January through December 2018 and classified them into four groups: (1) persons using real-time continuous glucose monitoring (rtCGM), (2) persons using any method of blood glucose monitoring (BGM) who followed prescribed use patterns (adherent), (3) persons who were prescribed BGM but were nonadherent in its use, and (4) no record of any form of BGM. Analyses compared these groups and the role that comorbidities (Charlson Comorbidity Index [CCI]), and race/ethnicity played on group assignment, diabetes-related inpatient hospitalizations, and costs. Results: Among the 1,329,061 persons assessed, 38.14% had no record of glucose monitoring and 35.42% were BGM nonadherent. Similarly, among the 629,514 beneficiaries with a CCI risk score of ≥2, 466,646 (74.13%) were either nonadherent to BGM or had no monitoring record. The percentage of White (3.65%) rtCGM adherent beneficiaries was significantly larger than Black (1.58%) and Hispanic (1.28%) beneficiaries, both P < 0.0001. Hospitalizations and costs were higher for Black and Hispanic beneficiaries versus Whites within the risk score ≥ 2 group regardless of glucose monitoring method. Conclusions: Race is associated with increased hospitalizations and costs associated with diabetes care and absence of any form of BGM was associated with higher rates of comorbidities. Persons of color were less likely to use rtCGM despite Medicare coverage. New initiatives that promote diabetes self-management education and support services are needed to improve utilization of glucose monitoring within the Medicare diabetes population.

Continuous Glucose Monitoring (CGM) Is a Tool, Not a Reward: Unjustified Insurance Coverage Criteria Limit Access to CGM

Recent studies have demonstrated the clinical utility of continuous glucose monitoring (CGM) use in type 2 diabetes (T2D) patients who are treated with intensive insulin management. Large retrospective database analyses of T2D patients treated with less-intensive therapies have also shown that CGM use was associated with significant reductions in hemoglobin A1c levels and health resource utilization, including diabetes-related hospitalizations and emergency room care. Despite the growing body of evidence supporting CGM use in the broader T2D population, current eligibility criteria required by public and many private insurers are denying millions of individuals with T2D access to this valuable technology. In this article, we discuss an evidence-based rationale for modifying current eligibility requirements for CGM coverage.

Use of Flash Continuous Glucose Monitoring Is Associated With A1C Reduction in People With Type 2 Diabetes Treated With Basal Insulin or Noninsulin Therapy

BACKGROUND

Glycemic control is suboptimal in many individuals with type 2 diabetes. Although use of flash continuous glucose monitoring (CGM) has demonstrated A1C reductions in patients with type 2 diabetes treated with a multiple daily injection or insulin pump therapy regimen, the glycemic benefit of this technology in patients with type 2 diabetes using nonintensive treatment regimens has not been well studied.

METHODS

This retrospective, observational study used the IBM Explorys database to assess changes in A1C after flash CGM prescription in a large population with suboptimally controlled type 2 diabetes treated with nonintensive therapy. Inclusion criteria were diagnosis of type 2 diabetes, age <65 years, treatment with basal insulin or noninsulin therapy, naive to any CGM, baseline A1C ≥8%, and a prescription for the FreeStyle Libre flash CGM system during the period between October 2017 and February 2020. Patients served as their own control subject.

RESULTS

A total of 1,034 adults with type 2 diabetes (mean age 51.6 ± 9.2 years, 50.9% male, baseline A1C 10.1 ± 1.7%) were assessed. More patients received noninsulin treatments (n = 728) than basal insulin therapy (n = 306). We observed a significant reduction in A1C within the full cohort: from 10.1 ± 1.7 to 8.6 ± 1.8%; Δ -1.5 ± 2.2% (P <0.001). The largest reductions were seen in patients with a baseline A1C ≥12.0% (n = 181, A1C reduction -3.7%, P <0.001). Significant reductions were seen in both treatment groups (basal insulin -1.1%, noninsulin -1.6%, both P <0.001).

CONCLUSION

Prescription of the flash CGM system was associated with significant reductions in A1C in patients with type 2 diabetes treated with basal insulin or noninsulin therapy. These findings provide evidence for expanding access to flash CGM within the broader population of people with type 2 diabetes.

Flash CGM Is Associated With Reduced Diabetes Events and Hospitalizations in Insulin-Treated Type 2 Diabetes

Purpose

Suboptimal glycemic control among individuals with diabetes is a leading cause of hospitalizations and emergency department utilization. Use of flash continuous glucose monitoring (flash CGM) improves glycemic control in type 1 and type 2 diabetes, which may result in lower risk for acute and chronic complications that require emergency services and/or hospitalizations.

Methods

In this retrospective, real-world study, we analyzed IBM MarketScan Commercial Claims and Medicare Supplemental databases to assess the impact of flash CGM on diabetes-related events and hospitalizations in a cohort of 2463 individuals with type 2 diabetes who were on short- or rapid-acting insulin therapy. Outcomes were changes in acute diabetes-related events (ADE) and all-cause inpatient hospitalizations (ACH), occurring during the first 6 months after acquiring the flash CGM system compared with event rates during the 6 months prior to system acquisition. ICD-10 codes were used to identify ADE for hypoglycemia, hypoglycemic coma, hyperglycemia, diabetic ketoacidosis, and hyperosmolarity.

Results

ADE rates decreased from 0.180 to 0.072 events/patient-year (hazard ratio [HR]: 0.39 [0.30, 0.51]; P < 0.001) and ACH rates decreased from 0.420 to 0.283 events/patient-year (HR: 0.68 [0.59 0.78]; P < 0.001). ADE reduction occurred regardless of age or gender.

Conclusions

Acquisition of the flash CGM system was associated with reductions in ADE and ACH. These findings provide support for the use of flash CGM in type 2 diabetes patients treated with short- or rapid-acting insulin therapy to improve clinical outcomes and potentially reduce costs.

Impact of the 2013 National Rollout of CMS Competitive Bidding Program: The Disruption Continues

OBJECTIVE

Use of glucose monitoring is essential to the safety of individuals with insulin-treated diabetes. In 2011, the Centers for Medicare & Medicaid Services (CMS) implemented the Medicare Competitive Bidding Program (CBP) in nine test markets. This resulted in a substantial disruption of beneficiary access to self-monitoring of blood glucose (SMBG) supplies and significant increases in the percentage of beneficiaries with either reduced or no acquisition of supplies. These reductions were significantly associated with increased mortality, hospitalizations, and costs. The CBP was implemented nationally in July 2013. We evaluated the impact of this rollout to determine if the adverse outcomes seen in 2011 persisted.

RESEARCH DESIGN AND METHODS

This longitudinal study followed 529,627 insulin-treated beneficiaries from 2009 through 2013 to assess changes in beneficiary acquisition of testing supplies in the initial nine test markets (TEST, n = 43,939) and beneficiaries not affected by the 2011 rollout (NONTEST, n = 485,688). All Medicare beneficiary records for analysis were obtained from CMS.

RESULTS

The percentages of beneficiaries with partial/no SMBG acquisition were significantly higher in both the TEST (37.4%) and NONTEST (37.6%) groups after the first 6 months of the national CBP rollout, showing increases of 48.1% and 60.0%, respectively (both P < 0.0001). The percentage of beneficiaries with no record for SMBG acquisition increased from 54.1% in January 2013 to 62.5% by December 2013.

CONCLUSIONS

Disruption of beneficiary access to their prescribed SMBG supplies has persisted and worsened. Diabetes testing supplies should be excluded from the CBP until transparent, science-based methodologies for safety monitoring are adopted and implemented.

The Financial Impact of Inaccurate Blood Glucose Monitoring Systems

OBJECTIVE

An in silico study of type 1 diabetes (T1DM) patients utilized the UVA-PADOVA Type 1 Diabetes Simulator to assess the effect of patient blood glucose monitoring (BGM) system accuracy on clinical outcomes. We applied these findings to assess the financial impact of BGM system inaccuracy.

METHODS

The study included 43 BGM systems previously assessed for accuracy according to ISO 15197:2003 and ISO 15197:2013 criteria. Glycemic responses for the 100 in silico adult T1DM subjects were generated, using each meter. Changes in estimated HbA1c, severe hypoglycemic events, and health care resource utilization were computed for each simulation. The HbA1c Translator modeling approach was used to calculate the financial impact of these changes.

RESULTS

The average cost of inaccuracy associated with the entire group of BGM systems was £155 per patient year (PPY). The average additional cost of BGM systems not meeting the ISO 15197:2003 standard was an estimated £178 PPY more than an average system that fulfills the standard and an estimated £235 PPY more than an average system that appears to meet the ISO 15197:2013 standard.

CONCLUSION

There is a clear relationship between BGM system accuracy and cost, with the highest costs being associated with BGM systems not meeting the ISO 15197:2003 standard. Lower costs are associated with systems meeting the ISO 15197:2013 system accuracy criteria. Using BGM systems that meet the system accuracy criteria of the ISO 15197:2013 standard can help reduce the clinical and financial consequences associated with inaccuracy of BGM devices.

Continuous Glucose Monitoring in Older Adults With Type 1 and Type 2 Diabetes Using Multiple Daily Injections of Insulin: Results From the DIAMOND Trial

OBJECTIVE

The objective was to determine the effectiveness of real-time continuous glucose monitoring (CGM) in adults ≥ 60 years of age with type 1 (T1D) or type 2 (T2D) diabetes using multiple daily insulin injections (MDI).

METHODS

A multicenter, randomized trial was conducted in the United States and Canada in which 116 individuals ≥60 years (mean 67 ± 5 years) with T1D (n = 34) or T2D (n = 82) using MDI therapy were randomly assigned to either CGM (Dexcom™ G4 Platinum CGM System® with software 505; n = 63) or continued management with self-monitoring blood glucose (SMBG; n = 53). Median diabetes duration was 21 (14, 30) years and mean baseline HbA1c was 8.5 ± 0.6%. The primary outcome, HbA1c at 24 weeks, was obtained for 114 (98%) participants.

RESULTS

HbA1c reduction from baseline to 24 weeks was greater in the CGM group than Control group (-0.9 ± 0.7% versus -0.5 ± 0.7%, adjusted difference in mean change was -0.4 ± 0.1%, P < .001). CGM-measured time >250 mg/dL ( P = .006) and glycemic variability ( P = .02) were lower in the CGM group. Among the 61 in the CGM group completing the trial, 97% used CGM ≥ 6 days/week in month 6. There were no severe hypoglycemic or diabetic ketoacidosis events in either group.

CONCLUSION

In adults ≥ 60 years of age with T1D and T2D using MDI, CGM use was high and associated with improved HbA1c and reduced glycemic variability. Therefore, CGM should be considered for older adults with diabetes using MDI.

Impact of CMS Competitive Bidding Program on Medicare Beneficiary Safety and Access to Diabetes Testing Supplies: A Retrospective, Longitudinal Analysis

OBJECTIVE

In 2011, the Centers for Medicare & Medicaid Services (CMS) launched the Competitive Bidding Program (CBP) in nine markets for diabetes supplies. The intent was to lower costs to consumers. Medicare claims data (2009-2012) were used to confirm the CMS report (2012) that there were no disruptions in acquisition caused by CBP and no changes in health outcomes.

RESEARCH DESIGN AND METHODS

The study population consisted of insulin users: 43,939 beneficiaries in the nine test markets (TEST) and 485,688 beneficiaries in the nontest markets (NONTEST). TEST and NONTEST were subdivided: those with full self-monitoring of blood glucose (SMBG) supply acquisition (full SMBG) according to prescription and those with partial/no acquisition (partial/no SMBG). Propensity score-matched analysis was performed to reduce selection bias. Outcomes were impact of partial/no SMBG acquisition on mortality, inpatient admissions, and inpatient costs.

RESULTS

Survival was negatively associated with partial/no SMBG acquisition in both cohorts (P < 0.0001). Coterminous with CBP (2010-2011), there was a 23.0% (P < 0.0001) increase in partial/no SMBG acquisition in TEST vs. 1.7% (P = 0.0002) in NONTEST. Propensity score-matched analysis showed beneficiary migration from full to partial/no SMBG acquisition in 2011 (1,163 TEST vs. 605 NONTEST) was associated with more deaths within the TEST cohort (102 vs. 60), with higher inpatient hospital admissions and associated costs.

CONCLUSIONS

SMBG supply acquisition was disrupted in the TEST population, leading to increased migration to partial/no SMBG acquisition with associated increases in mortality, inpatient admissions, and costs. Based on our findings, more effective monitoring protocols are needed to protect beneficiary safety.

Ultra-long pharmacokinetic properties of insulin degludec are comparable in elderly subjects and younger adults with type 1 diabetes mellitus

Background

Management of diabetes in elderly subjects is complex and careful management of glucose levels is of particular importance in this population because of an increased risk of diabetes-related complications and hypoglycaemia.

Objective

The aim of this study was to evaluate the pharmacokinetic and pharmacodynamic properties of insulin degludec (IDeg), a basal insulin with an ultra-long duration of action, in elderly subjects with type 1 diabetes compared with younger adults.

Methods

This trial was a randomised, double-blind, two-period, crossover trial conducted in a single centre and included both inpatient and outpatient periods. Subjects were men and women aged 18–35 years inclusive (younger adult group) or ≥65 years (elderly group) with type 1 diabetes who received IDeg (0.4 U/kg) via subcutaneous injection in the thigh once-daily for six days. Following 6-day dosing, a 26-hour euglycaemic glucose clamp procedure was conducted to evaluate the steady-state pharmacodynamic effects of IDeg. Blood samples were taken for pharmacokinetic analysis up to 120 h post-dose. Pharmacokinetic endpoints included the total exposure of IDeg, ie the area under the IDeg serum concentration curve during one dosing interval at steady state (AUC_IDeg,τ,SS) (τ = 0–24 h, equal to one dosing interval) and the maximum IDeg serum concentration at steady state (C_max,IDeg,SS). Pharmacodynamic endpoints included the total glucose-lowering effect of IDeg, ie the area under the glucose infusion rate (GIR) curve at steady state (AUC_GIR,τ,SS), and the maximum GIR at steady state (GIR_max,IDeg,SS).

Results

Total exposure (AUC_IDeg,τ,SS) and maximum concentration (C_max,IDeg,SS) of IDeg were comparable between elderly subjects and younger adults. Estimated mean age group ratios (elderly/younger adult) for AUC_IDeg,τ,SS and C_max,IDeg,SS and corresponding two-sided 95 % confidence intervals (CIs) were 1.04 (95 % CI 0.73–1.47) and 1.02 (95 % CI 0.74–1.39), respectively. Mean AUC_{IDeg,0–12h,SS}/AUC_IDeg,τ,SS was 53 % in both younger adult and elderly subjects, showing that in both age groups IDeg exposure was evenly distributed across the first and second 12 h of the 24-hour dosing interval. No statistically significant differences were observed between younger adult and elderly subjects with regard to AUC_GIR,τ,SS (the primary endpoint of this study) and GIR_max,IDeg,SS. Estimated mean age group ratios (elderly/younger adult) for AUC_GIR,τ,SS and GIR_max,IDeg,SS and corresponding two-sided 95 % CIs were 0.78 (95 % CI 0.47–1.31) and 0.80 (95 % CI 0.54–1.17), respectively. Duration of action was beyond the clamp duration of 26 h in all subjects.

Conclusions

The exposure of IDeg at steady state during once-daily dosing was similar in younger adult and elderly subjects. The glucose-lowering effect of IDeg was numerically lower in elderly subjects compared with younger adults, but no significant differences were observed between age groups. The ultra-long pharmacokinetic and pharmacodynamic properties of IDeg observed in younger adults were preserved in elderly subjects with type 1 diabetes.

Clinical trials.gov number: NCT00964418

Penny wise and pound foolish: will shortsighted cost reduction measures compromise patient access to promising self-monitoring of blood glucose technology?

In this issue of Journal of Diabetes Science and Technology, Grady and coauthors enrolled 101 patients with type 1 and type 2 diabetes to evaluate new technology incorporated into the LifeScan VerioPro and VerioIQ blood glucose meters. The "pattern detection" software provides real-time, onscreen messages that alert users to patterns of high glucose (fasting and premeal) and low glucose as they are detected. The study showed that most participants possess a good understanding of the factors that can cause hyperglycemia; however, their understanding of the causes of hypoglycemia events was not as strong. Nevertheless, more than 70% of participants indicated they preferred to use a blood glucose meter that provides pattern detection capability. Although not designed to assess the impact of the pattern detection tool on clinical outcomes, the study highlights the value of continuous innovation in self-monitoring of blood glucose (SMBG) technology among manufacturers. Unfortunately, many patients may never have access to these systems due to reductions in Medicare reimbursement. Instead, they may be forced to use SMBG systems that are inaccurate and provide inadequate patient support. Stronger regulatory requirements are needed to ensure that all SMBG systems marketed to patients are accurate, reliable, and supported by adequate patient training, and current health care reimbursement policies should be restructured to encourage manufacturers to continue their efforts to develop innovative technology to further improve the utility and usability of their SMBG systems.

Performance variability of seven commonly used self-monitoring of blood glucose systems: clinical considerations for patients and providers

BACKGROUND

Blood glucose data are frequently used in clinical decision making, thus it is critical that self-monitoring of blood glucose (SMBG) systems consistently provide accurate results. Concerns about SMBG accuracy have prompted the development of newly proposed International Organization for Standardization (ISO) standards: ≥ 95% of individual glucose results shall fall within ± 15 mg/dl of the results of the manufacturer's reference procedure at glucose concentrations <100 mg/dl and within ± 15% for values ≥ 100 mg/dl. We evaluated seven marketed systems against the current and proposed ISO criteria (criterion A).

METHOD

Capillary blood samples were collected from 100 subjects and tested on seven systems: Accu-Chek Aviva Plus, Advocate Redi-Code, Element, Embrace, Prodigy Voice, TRUEbalance, and WaveSense Presto. Results were compared with manufacturer's documented reference system, YSI or perchloric acid hexokinase; three different strip lots from each system were tested on each subject, in duplicate.

RESULTS

Compared against current ISO criteria (≥ 95% within ± 15 mg/dl for values <75 mg/dl and ± 20% for values ≥ 75 mg/dl) the Accu-Chek Aviva Plus, Element, and WaveSense Presto systems met accuracy criteria. However, only the Accu-Chek Aviva Plus met the proposed ISO criteria (criterion A) in all three lots. The other six systems failed to meet the criteria in at least two of the three lots, showing lot-to-lot variability, high/low bias, and variations due to hematocrit.

CONCLUSIONS

Inaccurate SMBG readings can potentially adversely impact clinical decision making and outcomes. Clinicians can reduce controllable variables by prescribing accurate SMBG systems. Adherence to the proposed ISO criteria should enhance patient safety by improving the accuracy of SMBG systems.

Effect of increasing duration of diabetes mellitus type 2 on glycated hemoglobin and insulin sensitivity

Non-insulin dependent diabetes mellitus (NIDDM) is the most rapidly growing chronic metabolic disorder in the world. With advancement in the age and duration of diabetes there is a gradual tendency for the level of blood sugar to rise along with a subsequent increase in the HbA1c as well as in the fasting insulin level. Whether this is an aging process or increased frequency of diabetes is still controversial. The correlation between glucose and insulin sensitivity is consistent with the idea that the degree of chronic hyperglycemia is a cause of excessive insulin resistance in type 2 diabetes, i.e. the insulin resistance which characterizes type 2 diabetes but not nondiabetic subjects matched for age, gender, family history and duration of diabetes. The study comprised a total of 76 subjects out of which 30 were normal, non-diabetic persons and the rest 46 were diabetics with different duration of time in years, after being diagnosed diabetic. Data was analyzed after dividing the subjects into four groups-Group 1 comprised of one year old diabetics, Group 2 was made up of those, who had diabetes, for the past 2-5 years, Group 3 included patients who were diabetic since more than 5 years and Group 4 included non-diabetics as the normal control group. The results obtained indicated that the HbA1c levels showed a significant increase with the duration of diabetes as well as the insulin level showed a significant correlation after adjustment for age, sex and duration of diabetes.

Age and tissue specific differences in the development of acute insulin resistance following injury

Injuries, hemorrhage, sepsis, burn, and critical illnesses all induce insulin resistance, and insulin resistance is strongly associated with advancing age. However, the effect of age on injury induced insulin resistance is not well studied. We performed surgical trauma in male rats of three different ages (3-, 6-, and 10-weeks old). Rats were either hemorrhaged to a mean arterial pressure of 35-40 mmHg and subsequently maintained at that pressure for up to 90 min, or maintained without hemorrhage as controls. Results indicate that insulin-induced intracellular signaling was diminished in liver and skeletal muscle of 6- and 10-week old rats following trauma and hemorrhage. In even younger rats, immediately post-weaning ( approximately 3 weeks of age), insulin signaling was lost in liver, but not in skeletal muscle. Glucocorticoids can play a role in the chronic development of insulin resistance. Our results demonstrate that corticosterone levels were increased in 6- and 10-week old animals following hemorrhage, but little change was measured in 3-week old animals. Blockade of glucocorticoid synthesis prevented the development of insulin resistance in skeletal muscle, but not in liver of 6- and 10-week old rats. Moreover, skeletal muscle glucocorticoid receptor levels increased dramatically between 3 and 6 weeks of age. These results indicate that trauma and hemorrhage-induced hepatic insulin resistance occurs at all ages tested. However, there is no development of insulin resistance following trauma and hemorrhage in skeletal muscle of post-weaning rats. In skeletal muscle of 6- and 10-week old rats, inhibition of glucocorticoid levels prevents the development of insulin resistance.

Prevalence of diabetes mellitus in elderly patients received enteral nutrition long-term care service

The purpose of this study was to determinate the prevalence of undiagnosed diabetes mellitus (UDM) using glycated hemoglobin (GHb) among functionally dependent and severe cognitive depressed elderly long-term care (LTC) patients received enteral nutrition. The patients were divided into three categories: control, patients with (diabetes mellitus, DM) and without previously diagnoses (UDM) of DM. Demographic, functional and cognitive status, laboratory data and rate of death were recorded. Patients with HbA-1c level of 7% and more were diagnosed as diabetic. On the baseline, 26% of the patients presented with known DM. Patients from control and previously UDM groups presented with similar fasting plasma glucose (FPG) and post-prandial glucose (PPG) levels, but were different by HbA-1c levels (p<0.001). In 79% of patients suffering from UDM, HbA-1c levels was more than 7%, and in 24% of them more than 8%. Prevalence of UDM was 21%. Patients from UDM were presented as borderline group between Control group (C-G) and DM. Those differences presented by all general characteristics of the patients: age, functional and cognitive status, BMI, comorbidity, laboratory data and rate of death. This study suggests that 47% of LTC patients who received enteral nutrition suffered from DM, and 44% of them were undiagnosed. The authors recommend that the GHb is a simple and an effective laboratory analysis in detection of DM in this group of patients.

Diabetes mellitus in the extreme longevity

Epidemiological studies have revealed a progressive increase in the prevalence of diabetes mellitus in the elderly. Numerous factors are responsible for this trend, among them there are (a) the long-lasting disease due the improved therapeutic remedial (pharmacological, dietary treatments and physical activity), (b) the increased life span expectancy. The prevalence of diabetes mellitus in long living subjects is lower than in elderly people (subjects aged from 65 to 84). Senile diabetes is prevalent in long living people, and usually begins after 90 years. The incidence of neodiagnosed diabetes is higher in the oldest old than in the elderly people. Based on the results, diabetes mellitus is a negative factor for survival, and does not usually allow to achieve very old age, i.e. centenarian.

The implementation of nutritional advice for people with diabetes

These consensus-based recommendations emphasize the practical implementation of nutritional advice for people with diabetes, and describe the provision of services required to provide the information. Important changes from previous recommendations include greater flexibility in the proportions of energy derived from carbohydrate and monounsaturated fat, further liberalization in the consumption of sucrose, more active promotion of foods with a low glycaemic index, and greater emphasis on the provision of nutritional advice in the context of wider lifestyle changes, particularly physical activity. Monounsaturated fats are now promoted as the main source of dietary fat because of their lower susceptibility to lipid peroxidation and consequent lower atherogenic potential. Consumption of sucrose for patients who are not overweight can be increased up to 10% of daily energy provided that this is eaten in the context of a healthy diet and distributed throughout the day [corrected]. Evidence is presented for the effectiveness of advice provided by trained dieticians. The increasing evidence for the importance of good metabolic control and the growing requirement for measures to prevent Type 2 diabetes in an increasingly obese population will require major expansion of dietetic services if the standards in National Service Frameworks are to be successfully implemented.

Cognitive impairment, physical disability and depressive symptoms in older diabetic patients: the Fremantle Cognition in Diabetes Study

OBJECTIVE

To determine whether the prevalence of dementia, depression and/or disability in older diabetic subjects warrants an active screening approach by diabetes health care workers.

PATIENTS AND METHODS

The initial 223 members of a cohort of 529 eligible diabetic subjects, aged 70 years or over, were screened for cognitive impairment (using the Mini-Mental State Examination (MMSE) and Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE)), physical impairments and depressive symptoms.

RESULTS

Virtually all subjects were community-dwelling (99%) and mobile (86%) and relatively few had moderate or severe deficits in activities of daily living (ADL) (17.5%). The prevalences of cognitive impairment and probable dementia estimated from the screening tests were high (range 10.8-17.5%) compared with population studies. Any deficit with ADL was reported by 53% of the subjects and common problems included urinary and faecal incontinence. Scores consistent with clinical depression were reported by 14.2% of the sample but 50.2% of the remainder reported one or more depressive symptoms below the cut-off point for clinical depression. Only 36% of the study subjects were free of deficits in any domain.

CONCLUSIONS

Community-living older diabetic subjects have high rates of cognitive impairment, deficits in physical function and depressive symptomatology suggesting that screening programs for functional impairments and depression may be beneficial in health care systems that manage older diabetic patients.

[A case of brittle diabetes in a 94-year-old man with vascular dementia, visual disturbance and hearing difficulty]

A 94-year-old man had with vascular dementia, visual disturbance, hearing difficulty and speech and motor disturbance. He had a history of diabetes mellitus over 50 years. He developed brittle type diabetes. On administration of mixed type insulin (30: 70.12-18 units in the morning and 6-8 units in the evening), his blood glucose concentrations fluctuated from almost zero to 500-600 mg/dl. After change to short acting regular insulin (4-5 units) before each meal and intermediate type insulin (2 units) before sleeping time, extreme hyperglycemia was not observed, but the brittleness with frequent hypoglycemia persisted. The hypoglycemic symptoms were absent at the time of striking hypoglycemia: it was thought that the patient was condition unaware of hypoglycemia. The cause of the brittle diabetes in the extremely elderly was thought to be depletion of endocrine insulin secretion due to marked beta-cell reduction and/or beta-cell exhaustion secondary to long term duration of diabetes. Daily detailed observation is required to care for such mentally deteriorated patient with brittle diabetes.

Acarbose in the treatment of elderly patients with type 2 diabetes

AIMS

To study the effect of acarbose, an alpha-glucosidase inhibitor, on glycemic control in elderly patients with type 2 diabetes.

METHODS

Elderly patients with type 2 diabetes treated with diet alone were randomly treated in a double-blind fashion with placebo (n=99) or acarbose (n=93) for 12 months.

RESULTS

After 12 months of therapy, there was a statistically significant difference in the change in glycated haemoglobin (HbA(1c)) (-0.6%) in the acarbose group versus placebo, as well as in the incremental post-prandial glucose values (-2.1 mmol h/l) and mean fasting plasma glucose (-0.7 mmol/l). Although there was no effect of acarbose on insulin release, there was a clear effect of acarbose to decrease relative insulin resistance (-0.8) (HOMA method). In addition, acarbose was generally well tolerated and safe in the elderly; most discontinuations were due to gastrointestinal side effects such as flatulence and diarrhea. There were no cases of hypoglycemia reported, and no clinically relevant changes in laboratory abnormalities or vital signs during the study.

CONCLUSIONS

Acarbose improves the glycemic profile and insulin sensitivity in elderly patients with type 2 diabetes who are inadequately controlled on diet alone.

Considerations on blood glucose management in Type 2 diabetes mellitus

In recent years the benefits of more intensive management in preventing or delaying the development and progression of diabetic complications have been well documented. What is not as well documented is how to motivate the person with diabetes to manage the condition, how to set, assess and quantify glucose goals, and the glucose variables that should be routinely measured. This review discusses the importance of setting targets and communicating them in a way that the patient understands. When aiming for a glycaemia target, balance is required (1) between achieving reduction of complications and causing an increased degree of hypoglycaemia, and (2) between what is achievable and what degree of benefit is gained. Target values given in guidelines should be adapted by the clinician to take into account the patient's susceptibility to hypoglycaemia, stage and type of complications, age and life expectancy, co-morbidity, social environment, understanding of the steps required and level of commitment to the treatment. Several suggestions are given regarding possible improvements and amendments to existing guidelines for diabetes management in treating to glucose goal. For example, attention should be drawn to the need to individualize goals and to consider education, long-term support, patient needs and treatment outcome when formulating diabetes management plans. The relative properties of the different glucose variables-fasting plasma glucose (FPG), postprandial plasma glucose (PPG), glycated haemoglobin A(1c) (HbA(1c)), and glycated protein-in terms of their convenience of measurement, usefulness and relevance to the physician and patient are also evaluated. When prioritising the variables to be measured it is suggested that where feasible, HbA(1c) should be the standard measurement by which to gauge risk and treatment efficacy. Serial measurements should be made and, where possible, the use of blood glucose meters encouraged, in order to obtain a blood glucose profile for the patient.

Brittle diabetes in the elderly

Severely unstable, or brittle, diabetes can be disruptive to patients, carers and diabetes care teams. The peak age-group for brittle diabetes is 15-30, but there are reports of its occurrence in much older patients. To explore the characteristics and cause of brittle instability perceived by diabetologists in elderly patients we circulated a questionnaire to all UK hospital diabetic clinics for adults. 130 (56%) of 231 replied. Reports were obtained on 55 patients fulfilling our criteria for 'elderly brittle diabetes'--namely, age > or =60 years, on insulin treatment, and experiencing life-disrupting glycaemic instability of any kind associated with frequent or long admissions to hospital. Further information was obtained by a research nurse who visited the relevant clinics. The mean age of patients was 74 years (range 60-89) and 71% were female. The brittleness was classed as mixed glycaemic instability in 22 (44%), recurrent ketoacidosis in 16 (29%) and recurrent hypoglycaemia in 15 (27%). In 2 cases there was insufficient information for classification. The diabetes care team judged the brittleness to have multiple origins in two-thirds of the cases: problems with memory or behaviour were rare, and in only 4 cases was deliberate manipulation of therapy considered a possibility. 84% of the patients were living independently. In younger patients the principal manifestation of brittle diabetes is recurrent ketoacidosis. The present survey, though possibly subject to ascertainment bias, indicates that the patterns of instability and their causation may be different in elderly patients. With the growing use of insulin in the elderly, brittle diabetes is likely to be encountered increasingly often in this age-group.

Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings

BACKGROUND

Diabetes is a common chronic disease that is increasingly managed in primary care. Different systems have been proposed to manage diabetes care.

OBJECTIVES

To assess the effects of different interventions, targeted at health professionals or the structure in which they deliver care, on the management of patients with diabetes in primary care, outpatient and community settings.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, the Cochrane Controlled Trials Register (Issue 4 1999), MEDLINE (1966-1999), EMBASE (1980-1999), Cinahl (1982-1999), and reference lists of articles.

SELECTION CRITERIA

Randomised trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) analyses of professional, financial and organisational strategies aimed at improving care for people with Type 1 or Type 2 diabetes. The participants were health care professionals, including physicians, nurses and pharmacists. The outcomes included objectively measured health professional performance or patient outcomes, and self-report measures with known validity and reliability.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Forty-one studies were included involving more than 200 practices and 48,000 patients. Twenty-seven studies were RCTs, 12 were CBAs, and two were ITS. The studies were heterogeneous in terms of interventions, participants, settings and outcomes. The methodological quality of the studies was often poor. In all studies the intervention strategy was multifaceted. In 12 studies the interventions were targeted at health professionals, in nine they were targeted at the organisation of care, and 20 studies targeted both. In 15 studies patient education was added to the professional and organisational interventions. A combination of professional interventions improved process outcomes. The effect on patient outcomes remained less clear as these were rarely assessed. Arrangements for follow-up (organisational intervention) also showed a favourable effect on process outcomes. Multiple interventions in which patient education was added or in which the role of the nurse was enhanced also reported favourable effects on patients' health outcomes.

REVIEWER'S CONCLUSIONS

Multifaceted professional interventions can enhance the performance of health professionals in managing patients with diabetes. Organisational interventions that improve regular prompted recall and review of patients (central computerised tracking systems or nurses who regularly contact the patient) can also improve diabetes management. The addition of patient-oriented interventions can lead to improved patient health outcomes. Nurses can play an important role in patient-oriented interventions, through patient education or facilitating adherence to treatment.

Glycemic control in older subjects with type 2 diabetes mellitus in the Fremantle Diabetes Study

OBJECTIVES

We investigated whether there were differences in glycemic control in older compared with younger subjects with type 2 diabetes mellitus enrolled in the Fremantle Diabetes Study, a prospective study of diabetes care, control, and complications in an urban setting.

DESIGN

Cross-sectional observational study.

SETTING

University teaching hospital clinical research center.

PARTICIPANTS

A total of 1,205 patients with type 2 diabetes mellitus, 404 (33.3%) of whom were aged over 70 years and 83 (6.9%) aged over 80 years.

MEASUREMENTS

Fasting plasma glucose, HbA1c, body mass index, and waist/hip ratio.

RESULTS

In multiple linear regression analysis, age was inversely associated with glycemic control whereas duration of diabetes and treatment with either oral hypoglycemic agents or insulin were positively associated with glycemic control. For most age groups there was a significant worsening of glycemic control with duration of diabetes. Octogenarians differed significantly from younger age groups in that those with longer diabetes duration did not demonstrate the increase in hyperglycemia seen in other age groups. As a result, significantly greater proportions of these oldest diabetic subjects had satisfactory glycosylated hemoglobin levels compared with younger subjects.

CONCLUSIONS

Octogenarians do not demonstrate the usual progressive deterioration of glycemic control with diabetes duration seen in type 2 diabetes mellitus. The reasons for this difference are unknown but are likely to have clinical significance with regard to therapy and the development of diabetic complications.

Poorly controlled elderly Type 2 diabetic patients: the effects of increasing sulphonylurea dosages or adding metformin

AIMS

To assess the effects and safety of increasing sulphonylurea dosages or adding metformin in poorly controlled elderly Type 2 diabetic patients.

METHODS

A 18-month multicentre clinical study was performed on sulphonylurea-treated diabetic patients over 70 years of age with well-preserved renal function, steady fasting blood glucose > or = 200 mg/dl and HbA1c > or = 9%. Patients were randomly assigned to sulphonylurea increased up to its maximum dosage (1st group) or to addition of metformin (2nd group). Glycaemic control, lipid pattern, haemostatic status and safety were monitored during run-in, at baseline and at scheduled intervals for 18 months. Results refer to 85 patients in the 1st group and 89 patients in the 2nd with complete data.

RESULTS

Similar improvements in glycaemic levels were observed with both treatments within the first month and a similar decrease in HbA1c within the third month. No further changes occurred in glycaemic control. In the 1st group, fasting glucose (mmol/l, mean +/- SE) decreased from 14.21 +/- 0.49 to 9.88 +/- 0.21, average day-long glucose from 14.87 +/- 0.27 to 10.69 +/- 0.19 and HbAt1c(%) from 10.32 +/- 0.13 to 8.66 +/- 0.13. In the 2nd treatment group fasting glucose decreased from 14.59 +/- 0.61 to 9.05 +/- 37.28, average day-long glucose from 15.09 +/- 0.29 to 10.32 +/- 0.21 and HbA1c from 10.33 +/- 0.13 to 8.77+/-0.12 (for all P<0.0005). In this 2nd group, a decrease in LDL-cholesterol (P < 0.05) and an increase in HDL-cholesterol levels (P < 0.02) were also observed. In the 1st group, anthrombin III activity increased significantly (P<0.01). In the 2nd group, significant reductions in markers of platelet function (FP4 and betaTG, P < 0.01), thrombin generation (FPA, F1 + 2 and D-D, P<0.01), and fibrinolysis inhibition (PAI-1 activity, PAI-1 antigen, P< 0.001) were observed. Increases in some fibrinolytic activation markers (t-PA activity, and AT-III activity, P<0.01) occurred. Fasting lactate concentrations were unchanged in the metformin-treated group. No serious adverse effects were observed in either group.

CONCLUSIONS

These results suggest that either high sulphonylurea dosages or a therapy combining lower sulphonylurea dosages with metformin are effective and safe in an aged but healthy population. Metformin provides additional benefits counteracting several cardiovascular risk factors but must be administered with caution, bearing in mind the general contra-indications for the drug but not age alone.

The use of sulphonylureas in the elderly

Type 2 diabetes mellitus is a heterogeneous disorder characterised by defects in insulin secretion as well as reduced insulin action. During aging, glucose intolerance will gradually develop, and this is manifested primarily by an increase in the postprandial blood glucose response while fasting blood glucose levels are often less elevated. Abnormal beta-cell secretion of insulin is a main feature of this. Treatment of elderly patients with type 2 diabetes mellitus focuses on reduction of (hyperglycaemic) complaints and prevention of the development or progression of secondary complications. Although regular physical activity and dietary measures, aiming at bodyweight normalisation, are the cornerstones of therapy, pharmacological treatment with oral blood glucose lowering-agents often proves necessary to control the hyperglycaemia. In the United Kingdom Prospective Diabetes Study (UKPDS) it was clearly shown that patients with type 2 diabetes mellitus who were intensively treated with oral blood glucose-lowering agents or insulin developed less microvascular complications. The question whether achievement of strict metabolic control is also of benefit in elderly patients, is still unanswered. Sulphonylureas are drugs which stimulate insulin secretion by enhancing the release of insulin from the pancreatic beta-cells without an effect on insulin synthesis. They are frequently used in the treatment of type 2 diabetes mellitus, and several preparations are available. In general, there are no major differences in effectiveness between the various sulphonylureas. Long term treatment with sulphonylureas will decrease fasting and postprandial plasma glucose levels by 3 to 5 mmol/L, and glycosylated haemoglobin by 20%. However, after its initial decline, plasma glucose level will often go up slightly during the following months to years. Sulphonylureas are usually well tolerated. Hypoglycaemia is the most frequently occurring adverse effect, which may be very serious and damaging in the elderly. It has been associated primarily with long-acting sulphonylureas, like chlorpropamide and glibenclamide (glyburide). Hypoglycaemic episodes may trigger serious events like myocardial infarction or stroke. Therefore, shorter-acting compounds like tolbutamide and gliclazide have been relatively well tolerated and appear to be the best choice to treat elderly patients. It is advisable to start with a low dose and increase the dose, when needed, in small steps. The efficacy of sulphonylureas is much greater when they are taken before a meal. Because of the fact that type 2 diabetes mellitus is a progressive disease, and residual beta-cell function decreases with time, insulin therapy may ultimately be warranted in a significant number of patients.

Usefulness of fructosamine for monitoring outpatients with diabetes

BACKGROUND

Measurements of total glycohemoglobin (glycoHb) or hemoglobin A1c are routinely used to evaluate intermediate-to-long term glycemic control in patients with diabetes. However, despite the recent availability of more rapid methods for glycohemoglobin determination, it remains difficult in many institutions to obtain same-day glycoHb determinations in time to assist physicians with management of outpatients with diabetes. Hence, we investigated whether fructosamine, which reflects very recent (2 to 3 weeks) glycemic control and which can be assayed more rapidly in our laboratory, could serve as a useful adjunct to glycoHb for management of these patients.

METHODS

Diabetes control in outpatients managed using fructosamine, fasting serum glucose, and glycoHb (concentrations from the prior visit) was compared with that for outpatients monitored using fasting serum glucose and prior glycoHb alone. The relative usefulness of fructosamine, current and prior glycoHb, and "fasting" serum glucose for evaluation and management of outpatients with diabetes was compared. In addition, the acceptance of fructosamine by physicians was evaluated by a questionnaire.

RESULTS

Same-day fructosamine concentrations correlated better with current glycoHb than did either prior glycoHb or current fasting serum glucose concentrations. However, the availability of same-day fructosamine results did not objectively improve diabetes control compared with that obtained using only fasting serum glucose values and prior glycoHb concentrations. Nonetheless, most examining physicians stated that same-day fructosamine concentrations helped them significantly with diabetes management, primarily because many patients do not adequately monitor home blood glucose levels.

CONCLUSIONS

Fructosamine may be a useful adjunctive test for management of outpatients with diabetes in situations where it is not practical to obtain same-day glycoHb concentrations, for patients less compliant with home glucose monitoring, or where recent changes in insulin dose or clinical presentation might not be reflected in the glycoHb levels.

The Endocrinology of Aging

Physiologic systems have substantial reserves in younger individuals. The process of aging and intercurrent pathologic processes gradually eliminate these reserves. Changes in endocrine systems, including menopause in women, androgen deficiency in men, loss of skeletal mass, decrease in growth hormone serum concentrations, and increased incidence of type 2 diabetes are all more common or certain in older individuals. This review summarizes the progression of each of these processes with age, the potential outcomes of the untreated process, and the treatment outcomes for these age-related losses. Maintenance of a premenopausal lipid profile presumably protects against cardiovascular events. Maintenance of skeletal mass reduces fracture risk and risk for loss of mobility and independence. Testosterone replacement in hypogonadal older men improves strength and presumably function and independence. Growth hormone therapy is reported to have similar effects. Improvement of long-term outcomes in older type 2 diabetics, however, is more difficult to demonstrate.

Review of management of type 2 diabetes mellitus

BACKGROUND

Commonly used drugs for type 2 diabetes are not ideal. The sulphonylureas, especially potent and long-acting agents such as glibenclamide, can induce hypoglycaemia, while metformin carries the risk of lactic acidosis.

AIM

To review the management of type 2 diabetes at the major teaching hospital in Tasmania, Australia, principally to determine the extent of use of glibenclamide and metformin in the elderly and patients where published contraindications are present.

METHODS

A retrospective review of the medical records for 150 consecutive patients with type 2 diabetes admitted to the hospital in mid-1997, was performed. An extensive range of demographic and clinical variables was recorded for each patient. These included the duration of type 2 diabetes, the presence of other medical conditions, medication history, presence of any contraindications to the use of metformin or sulphonylureas, biochemical measures of diabetic control, and the presence of any diabetic complications.

RESULTS

The mean (+/-SD) age of the 150 patients included in the study was 70.1+/-11.8 years. The mean body mass index was 28.7+/-6.2 kg/m2 and the mean recent HbA1c level was 86+/-21%; only 24.7% of patients had a HbA1c level of 7% or lower. Of the 45 patients using glibenclamide, 40 (88.9%) had one or more risk factors for hypoglycaemia: over 65 years of age, renal impairment, or cognitive impairment and living alone. The study also found an extensive use of metformin in patients with contraindications and at highest risk of developing lactic acidosis. Sixty-six out of 70 patients (94%) using metformin had at least one contraindication according to the manufacturer's prescribing information, 57% of patients had two or three contraindications and 14% of patients had more than three contraindications. More than 20% of the patients had a renal function below published exclusion criteria.

CONCLUSIONS

There was evidence of over-utilization of metformin and glibenclamide in type 2 diabetes patients most at risk of adverse reactions. Insulin therapy could be a safer and more effective management strategy in many of these patients.

Diabetes mellitus in older persons

The relative importance and mechanisms of deficient insulin secretion versus deficient action during aging are still debated. Whatever mechanisms eventually explain the emergence of impaired glucose tolerance during aging, the clinically important extrinsic modifiers of glycemic levels include diet, medications, activity, and chronic illness and stress. Although prospective studies are not available in the elderly, retrospective studies suggest that good blood glucose control reduces the likelihood and severity of stroke, cardiovascular disease, visual impairment, nephropathy, infections, and even cognitive dysfunction. Good control also seems to reduce nocturia, polyuria, and hypovolemia. Therapy of older persons begins with diet, exercise, and oral agents, failing which, insulin is employed. Since many of the newer oral agents carry less risk of hypoglycemia, achieving tighter control in the elderly has become more feasible.

Non-insulin-dependent diabetes mellitus in the elderly

The prevalence of non-insulin-dependent diabetes mellitus dramatically increases with age. Older diabetic subjects have an increased frequency of complications from diabetes compared with their younger counterparts and higher morbidity and mortality rates compared with age-matched non-diabetic controls. Elderly patients with diabetes are generally treated following the same approach as in younger patients: dietary therapy first, followed by oral hypoglycaemic agents and ultimately insulin. However, several specificities should be pointed out. Changes associated with ageing may affect the pharmacokinetics and pharmacodynamics of both sulphonylureas (increasing the risk of severe hypoglycaemia) and biguanides (increasing the risk of lactic acidosis). The best insulin regimen in old age is not known, but a twice-daily injection of a pre-mixed insulin preparation is usually recommended. Goals of therapy must be realistic and not cause disabling side-effects. The general practitioner plays a crucial role in the care of elderly diabetic patients, but access to a multidisciplinary specialized team may be necessary.