Individualize Type 2 Diabetes Regimens for Older Adults

More than 1 in 4 patients over 65 have type 2 diabetes...and you can help ensure they're managed appropriately.

Individualize care by focusing on health status, not just age.

Emphasize avoiding hypoglycemia. It's linked to an increased risk of falls, cognitive decline, and death. Explain that in many older adults, these risks often outweigh benefits of tight glucose control.

Reassess A1C goals regularly...and resist overtreatment.

Consider keeping current goals for healthier, independent older adults...especially if they're doing well.

But relax goals for others. For example, consider an A1C goal under 8% for those with multiple comorbidities...or an even looser goal for frail elderly, severe dementia patients, nursing home residents, etc.

Advise adjusting or deprescribing meds as A1C goals are relaxed.

Suggest avoiding glyburide and glimepiride...they're on the Beers Criteria due to risk of hypoglycemia. If a sulfonylurea is preferred because of cost, recommend glipizide at a starting dose of 2.5 mg/day.

If insulin is needed, suggest trying basal insulin in the AM instead of PM...lowering any mealtime doses...and avoiding sliding scales.

Continue to rely on metformin. It can be continued in stable kidney disease down to an estimated glomerular filtration rate of 30 mL/min.

Consider GLP-1 agonists or SGLT2 inhibitors for potential non-glycemic benefits...if patients can tolerate and afford them.

Point out that certain GLP-1 agonists (Victoza, etc) reduce CV risk and seem to protect the kidneys. Feel comfortable continuing these meds in older CV patients...if they can use a pen device.

Or SGLT2 inhibitors (Jardiance, etc) may reduce risk of CV events, heart failure, and kidney decline. Lean toward continuing these in older adults with CV disease or CV risks. Warn about dizziness and hypotension.

Explain DPP-4 inhibitors (Januvia, etc) have low hypoglycemia risk. But they're reasonable to deprescribe when loosening A1C goals.

See our chart, Drugs for Type 2 Diabetes, for considerations in renal dysfunction, side effects, and costs. And help optimize meds with our toolbox, Improving Diabetes Outcomes.

Key References

  • J Clin Endocrinol Metab 2019;104(5):1520-74
  • Diabetes Care 2019;42(Suppl 1):S139-S147
  • Diabetes Obes Metab 2019;21(7):1668-79
Pharmacist's Letter. July 2019, No. 350701

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