Overtreatment of Diabetes in Patients 75 Years or Older Hypoglycemia

The Physiology of Low Blood Sugar (Hypoglycemia) on Your Brain: SIMPLIFIED

Diabetes In Control. A free weekly diabetes newsletter for Medical Professionals. News and information for Medical Professionals.

Overtreatment of Diabetes in Patients 75 Years or Older

Overtreatment of Diabetes in Patients 75 Years or Older

Is overtreatment of diabetes a problem for older Americans? Recent studies show one-quarter of the population over the age of 75 who have type 2 diabetes are tightly managed with medications and are high risk for hypoglycemia.

There is an estimated 26% of the population over the age of 75 in the U.S. who have type 2 diabetes and require challenging glycemic management. Tight glucose management has been warranted to reduce the risk of microvascular complications, but recent studies show the risk outweighs the benefits due to hypoglycemia. For this reason, the American Diabetes Association (ADA) guidelines have directed treatment in the elderly population to be more relaxed, and in 2012, the ADA recommended higher HbA1c goals in these patients. Although these goals were increased, they have not been seen in clinical practice. Over the past 10 years, there have been newer treatments available to reduce the risk of hypoglycemia to go along with the updated guidelines. Dr. Susan Arnold and colleagues used a large U.S. outpatient database to investigate treatment choices in contemporary practice and how they are contributing to glycemic management.

The available HbA1c data consisted of 42,669 patients 75 and older with type 2 diabetes. Patients were placed into groups based on glycemic care and HbA1c levels: diet control (HbA1c less than 7 percent without glucose-lowering medications), tight control using high-risk medications (HbA1c less than 7 percent using insulin, sulfonylurea, or meglitinides), tight control using low-risk agents (HbA1c less than 7 percent taking medications with low risk for hypoglycemia), or groups with no high risk medications. HaA1c groups were observed as conservative control (HbA1c 7–8 percent), moderate control (HbA1c 8–9 percent), and poor control (HbA1c >9 percent).

Results from the study showed 26% of patients whose diabetes was not managed by diet alone and were tightly managed with medications were at a high risk for hypoglycemia. Patients with comorbidities were associated with a greater likelihood of taking high-risk agents, which contradicts conservative management recommended by guidelines. Although there is a large amount of agents that have a reduced risk of hypoglycemia, insulin or insulin secretagogues were still shown to be used at high rates in the elderly, despite lower HbA1c levels. These results point to the overtreatment of elderly patients with T2D.

Hypoglycemia has been associated with a number of issues, including myocardial infarction, heart failure, stroke, falls, dementia, and death. It also burdens a patient’s quality of life and wallet. It is clear that more efforts are needed to accurately follow guidelines when treating elderly patients with diabetes. This may be difficult for physicians, especially when de-escalation is recommended and the patient has comorbidities. Currently, guidelines use vague terminology when making recommendations (e.g., “glycemic goals for some older adults might be reasonably relaxed, using individual criteria”), warranting better evidence on when and how to lower the intensity of medications causing hypoglycemia.

Elderly patients with T2D should be closely monitored for hypoglycemia using HbA1c and blood glucose levels, as it may cause more harm than patients are aware. Physicians are encouraged to recommend therapy with lower risk and set goals based on current guidelines to avoid overtreatment of diabetes medications in the elderly.

In 2012, the ADA recommended a higher HbA1c goal in the elderly population to reduce the risk of hypoglycemia, but those changes have not effectively translated to clinical practice.

Out of 42,669 patients 75 and older with T2D not managed by diet alone, 26% of those patients were found to have diabetes that was tightly managed by medications and were at a high risk for hypoglycemia.

Currently, Currently Hypoglycemia , warranting better evidence on when and how to lower the intensity of medications in the elderly causing hypoglycemia.

Arnold, S., Lipska, K., Wang J, et al. “Use of Intensive Glycemic Management in Older Adults with Diabetes Mellitus.” J Am Geriatr Soc. 2018 Apr. doi: 10.1111/jgs.15335.

Standards of Medical Care in Diabetes—2018. Diabetes Care Jan 2018, 41 (Supplement 1) S1-S2; doi

Melissa Bailey, Pharm.D. Candidate, USF College of Pharmacy

Dapagliflozin Improves Glycemic Index in Patients with T1DM but Increases Risk for DKA

Semaglutide Causes Weight Loss in Type 2 Diabetes Regardless of Baseline BMI

50/50 Insulin Lispro & Insulin Lispro Protamine Suspension

Hypoglycemia , & Insulin Aspart

70/30 Insulin Human & Insulin Humin Protamine Suspension

Hypoglycemia

50/50 Insulin Lispro & Insulin Lispro Protamine Suspension

75/25 Insulin Lispro Protamine Suspension & Insulin Lispro

70/30 Insulin Human & Insulin Humin Protamine Suspension

70/30 Insulin Aspart & Protamine Mix, & Insulin Aspart