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AT THE IDF CONGRESS 2019
BUSAN, SOUTH KOREA – The question of whether or not strict glycemic control is appropriate for older adults was the subject of a debate between two experts at the 2019 congress of the International Diabetes Federation.
Current guidelines from the Endocrine Society addressing diabetes management in older adults call for shared decision making and individualized approaches, taking into account comorbidities, complications, and special situations.
Medha Munshi, MD, and Ryo Suzuki, MD, PhD, took differing approaches to the risk-versus-benefit equation for older patients.
The case against ...
Dr. Munshi, director of the Joslin geriatric diabetes program at Beth Israel Deaconess Medical Center, Boston, started the debate by stating, “Yes, strict glycemic control in the elderly is meaningless.”
She based this on two main points: The benefits of strict glycemic control in older adults are not clear, and the risks are “catastrophic and well documented.”
The first problem, said Dr. Munshi, is that there is a dearth of data in older adults. In a 2013 review of 2,484 diabetes-focused studies registered on clinicaltrials.gov, just 0.6% included participants who were older than 65 years, whereas 30.8% specifically excluded that age group, and 54.9% excluded people older than 70 years.
Another analysis of 440 studies that investigated treatments for type 2 diabetes showed that, of trials that did include older adults, more than three-quarters (76.8%) excluded those with comorbidities, nearly a third (29.5%) excluded people with polypharmacy or specific drugs, and 18.4% excluded those with cognitive impairment.
“So, the trials are not targeted toward older adults, and those that are, exclude people with multiple comorbidities, so the [participants] who are left in the trials are not [representative of the patients] we see in the clinic,” Dr. Munshi emphasized.
Among the major trials that evaluated intensive treatment versus usual care in type 2 diabetes – including the UK Prospective Diabetes Study (UKPDS), the Veterans Administration Diabetes Trial (VADT), and the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial – no macrovascular benefits were found except in UKPDS, and evidence of harm was found in ACCORD.
What those trials suggested, said Dr. Munshi, is that the patients who do better with intensive glycemic control are younger, have a shorter duration of disease, fewer complications and comorbidities at baseline, better overall health, and longer life expectancy.
In contrast, those at greater risk from the hypoglycemia associated with intensive glycemic control are people who are older and frail, have longer duration of diabetes, have macro- and microvascular complications and comorbidities, are unable to safely follow complex regimens, and have shorter life expectancy.
She also pointed to a 2010 retrospective cohort study that identified a U-shaped curve relationship between hemoglobin A1c and all-cause mortality and cardiac events, suggesting that “there is a threshold beyond which, if the control is tighter, then the risk of mortality increases.”
Medications used by older adults with diabetes also pose risks, as shown in a study published in 2011 of 99,628 emergency hospitalizations for adverse drug events among U.S. adults aged 65 years and older conducted during 2007-2009.
In that study, warfarin topped the list, but insulin was the second most common, and oral hypoglycemic agents were also in the top 5.
And those episodes of emergency hospitalization, another study found, were associated with a 3.4-fold increased risk for 5-year mortality.
“ It increases the risk of cognitive decline, depression, frailty, falls and fractures, functional decline, anxiety, and fear of hypoglycemia; and it lowers quality of life,” Dr. Munshi explained.
Other unintended consequences of strict glycemic control in older adults include difficulty coping with complex regimens, increased caregiver burden, loss of independence, and increased financial burden, she added.
Control in healthy adults
A valid question, Dr. Munshi said, is whether strict glycemic control might be appropriate for older adults who are still healthy.
She responded to that by explaining that there is a phenomenon of aging called homeostenosis, a physical limit beyond which homeostasis cannot be restored in the presence of stressors, such as hypoglycemia leading to a fall, hospitalization, delirium, and poor outcome.
Another reasonable question, she added, was whether strict glycemic control in older adults could be achieved more safely and with greater benefit by using newer agents with lower risks for hypoglycemia that have been found to have cardiovascular and renal benefits.
To that, she noted that it’s not clear whether those benefits are a result of glycemic control, that the duration of the trials has been short (2-3 years), and drug interactions and side effects in populations with multiple morbidities have not been studied. Moreover, “cost and availability need consideration,” she said.
And so, she concluded, “Is strict glycemic control in the elderly really worth the risk? My answer would be no.”
The case for ...
Dr. Suzuki, a professor in the division of diabetes, metabolism, endocrinology, rheumatology, and collagen diseases at Tokyo Medical University, argued that strict glycemic control in the elderly is not “meaningless.”
He began by pointing out that his country, Japan, is “one of the most highly aging societies in the world.”
His arguments were based on three points: The elderly population is “full of diversity;” HbA1c is “not a perfect marker of glycemic control;” and new glucose-lowering drug classes may have benefits beyond reduction of blood glucose levels.
He also noted that there is no consensus on the definition of “elderly.”
Most developed countries use age 65 years and older as the cut-off, but the United Nations defines being elderly as 60 years and older, whereas the International Diabetes Federation’s guideline for managing older people with type 2 diabetes, uses 70 and older. These differences, he asserted, emphasize “the difficulty to generalize the gap between calendar age and biological age.”
Dr. Suzuki also pointed out that the American Diabetes Association’s Standards of Medical Care in Diabetes 2019 does not mention age as a consideration in individualizing glycemic targets.
Instead, factors such as risk for hypoglycemia, disease duration, life expectancy, comorbidities, established vascular complications, patient preference, and resources/support systems are listed. “We need to evaluate and assess these factors individually for every patient,” he asserted.
“Older age is very heterogeneous. Some people are very robust and active, while others are sick and frail ... We need to be careful about the active, healthy people because sometimes they need more intensified treatment to prevent complications of diabetes.”
Dr. Suzuki also pointed out that people hold important positions that require good health well into their 60s and 70s. “In many countries, many older individuals with or without diabetes have responsibilities and play important roles in their societies. Diabetes can be a big barrier for them ... Sometimes it requires hospitalizations, and they need to stop business.”
He cited an observational study from a Swedish national database showing a significant difference in hospitalizations for heart failure for older adults with diabetes and HbA1c of between 6% and 7%, compared with 7%-8%, among both men and women aged 71-75 and 61-65 years. In that study, investigators found that poor glycemic control (HbA1c of more than 7%) was associated with an increased risk of hospitalization for heart failure in patients with type 2 diabetes.
“This is, of course, an observational study, so we cannot draw a conclusion, but still, it strongly suggests that lower than 7% may prevent hospitalization for heart failure in elderly people.”
Glycemic variability
Another point is that HbA1c does not reflect glycemic variability, so it’s impossible to tell just from that measure the extent to which an individual is experiencing hypoglycemia – that is, two people can have the same A1c level, yet one experiences frequent hypoglycemia whereas the other never does.
“So, determining treatment based solely on A1c may be risky,” Dr. Suzuki noted.
And recently, the availability of continuous glucose monitoring is shifting the definition of “strict” glycemic control from “average” glucose to “time in range,” which also allows for a determination of the key metric “time below range.”
Recent international guidelines advise that, for older adults, fewer than 1% of readings should be below 70 mg/dL (3.9 mmol/L), compared with fewer than 4% for most other individuals with diabetes.
Thus, “in terms of avoiding hypoglycemia, older adults have a ‘stricter’ range. In other words, less stringency for high-risk people does not always mean broader allowance range in any glycemic profiles,” Dr. Suzuki noted.
However, newer drugs that don’t increase the risk for hypoglycemia are available for patients with type 2 diabetes.
Dr. Suzuki pointed to his own 2018 study demonstrating that the dipeptidyl peptidase‐4 (DPP-4) inhibitor sitagliptin had a greater ability to reduce daily glucose fluctuations in drug-naive Japanese patients with type 2 diabetes, compared with the sulfonylurea glibenclamide.
Similarly, in the Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS), the DPP-4 inhibitor did not increase severe hypoglycemia in the subgroup of participants aged 75 years and older.
And in several of the recent cardiovascular outcomes trials demonstrating cardiovascular benefit for type 2 diabetes agents, those benefits have been just as robust among older participants, he stressed.
These include the Researching Cardiovascular Events With a Weekly Incretin in Diabetes (REWIND) trial, in which those aged above and below 66 years experienced similar results with dulaglutide, a GLP-1 agonist.
And the landmark Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG OUTCOME), which actually showed even greater protection against cardiovascular events among subjects aged 65 and older (hazard ratio, 0.86).
Also in the Dapagliflozin-Heart Failure (Dapa-HF) study, the SGLT-2 inhibitor reduced worsening of heart failure in patients with heart failure with reduced ejection fraction, regardless of age or presence of diabetes.
“I argue that older patients have rights to receive appropriate and effective treatment to prevent diabetes complications,” Dr. Suzuki concluded.
Dr. Munshi is a consultant for Sanofi and Lilly. Dr. Suzuki has received honoraria from MSD, Novo Nordisk, Novartis Pharma, Takeda, Mitsubishi Tanabe, and Eli Lilly Japan.
A version of this story originally appeared on Medscape.com.
AT THE IDF CONGRESS 2019
BUSAN, SOUTH KOREA – The question of whether or not strict glycemic control is appropriate for older adults was the subject of a debate between two experts at the 2019 congress of the International Diabetes Federation.
Current guidelines from the Endocrine Society addressing diabetes management in older adults call for shared decision making and individualized approaches, taking into account comorbidities, complications, and special situations.
Medha Munshi, MD, and Ryo Suzuki, MD, PhD, took differing approaches to the risk-versus-benefit equation for older patients.
The case against ...
Dr. Munshi, director of the Joslin geriatric diabetes program at Beth Israel Deaconess Medical Center, Boston, started the debate by stating, “Yes, strict glycemic control in the elderly is meaningless.”
She based this on two main points: The benefits of strict glycemic control in older adults are not clear, and the risks are “catastrophic and well documented.”
The first problem, said Dr. Munshi, is that there is a dearth of data in older adults. In a 2013 review of 2,484 diabetes-focused studies registered on clinicaltrials.gov, just 0.6% included participants who were older than 65 years, whereas 30.8% specifically excluded that age group, and 54.9% excluded people older than 70 years.
Another analysis of 440 studies that investigated treatments for type 2 diabetes showed that, of trials that did include older adults, more than three-quarters (76.8%) excluded those with comorbidities, nearly a third (29.5%) excluded people with polypharmacy or specific drugs, and 18.4% excluded those with cognitive impairment.
“So, the trials are not targeted toward older adults, and those that are, exclude people with multiple comorbidities, so the [participants] who are left in the trials are not [representative of the patients] we see in the clinic,” Dr. Munshi emphasized.
Among the major trials that evaluated intensive treatment versus usual care in type 2 diabetes – including the UK Prospective Diabetes Study (UKPDS), the Veterans Administration Diabetes Trial (VADT), and the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial – no macrovascular benefits were found except in UKPDS, and evidence of harm was found in ACCORD.
What those trials suggested, said Dr. Munshi, is that the patients who do better with intensive glycemic control are younger, have a shorter duration of disease, fewer complications and comorbidities at baseline, better overall health, and longer life expectancy.
In contrast, those at greater risk from the hypoglycemia associated with intensive glycemic control are people who are older and frail, have longer duration of diabetes, have macro- and microvascular complications and comorbidities, are unable to safely follow complex regimens, and have shorter life expectancy.
She also pointed to a 2010 retrospective cohort study that identified a U-shaped curve relationship between hemoglobin A1c and all-cause mortality and cardiac events, suggesting that “there is a threshold beyond which, if the control is tighter, then the risk of mortality increases.”
Medications used by older adults with diabetes also pose risks, as shown in a study published in 2011 of 99,628 emergency hospitalizations for adverse drug events among U.S. adults aged 65 years and older conducted during 2007-2009.
In that study, warfarin topped the list, but insulin was the second most common, and oral hypoglycemic agents were also in the top 5.
And those episodes of emergency hospitalization, another study found, were associated with a 3.4-fold increased risk for 5-year mortality.
“ It increases the risk of cognitive decline, depression, frailty, falls and fractures, functional decline, anxiety, and fear of hypoglycemia; and it lowers quality of life,” Dr. Munshi explained.
Other unintended consequences of strict glycemic control in older adults include difficulty coping with complex regimens, increased caregiver burden, loss of independence, and increased financial burden, she added.
Control in healthy adults
A valid question, Dr. Munshi said, is whether strict glycemic control might be appropriate for older adults who are still healthy.
She responded to that by explaining that there is a phenomenon of aging called homeostenosis, a physical limit beyond which homeostasis cannot be restored in the presence of stressors, such as hypoglycemia leading to a fall, hospitalization, delirium, and poor outcome.
Another reasonable question, she added, was whether strict glycemic control in older adults could be achieved more safely and with greater benefit by using newer agents with lower risks for hypoglycemia that have been found to have cardiovascular and renal benefits.
To that, she noted that it’s not clear whether those benefits are a result of glycemic control, that the duration of the trials has been short (2-3 years), and drug interactions and side effects in populations with multiple morbidities have not been studied. Moreover, “cost and availability need consideration,” she said.
And so, she concluded, “Is strict glycemic control in the elderly really worth the risk? My answer would be no.”
The case for ...
Dr. Suzuki, a professor in the division of diabetes, metabolism, endocrinology, rheumatology, and collagen diseases at Tokyo Medical University, argued that strict glycemic control in the elderly is not “meaningless.”
He began by pointing out that his country, Japan, is “one of the most highly aging societies in the world.”
His arguments were based on three points: The elderly population is “full of diversity;” HbA1c is “not a perfect marker of glycemic control;” and new glucose-lowering drug classes may have benefits beyond reduction of blood glucose levels.
He also noted that there is no consensus on the definition of “elderly.”
Most developed countries use age 65 years and older as the cut-off, but the United Nations defines being elderly as 60 years and older, whereas the International Diabetes Federation’s guideline for managing older people with type 2 diabetes, uses 70 and older. These differences, he asserted, emphasize “the difficulty to generalize the gap between calendar age and biological age.”
Dr. Suzuki also pointed out that the American Diabetes Association’s Standards of Medical Care in Diabetes 2019 does not mention age as a consideration in individualizing glycemic targets.
Instead, factors such as risk for hypoglycemia, disease duration, life expectancy, comorbidities, established vascular complications, patient preference, and resources/support systems are listed. “We need to evaluate and assess these factors individually for every patient,” he asserted.
“Older age is very heterogeneous. Some people are very robust and active, while others are sick and frail ... We need to be careful about the active, healthy people because sometimes they need more intensified treatment to prevent complications of diabetes.”
Dr. Suzuki also pointed out that people hold important positions that require good health well into their 60s and 70s. “In many countries, many older individuals with or without diabetes have responsibilities and play important roles in their societies. Diabetes can be a big barrier for them ... Sometimes it requires hospitalizations, and they need to stop business.”
He cited an observational study from a Swedish national database showing a significant difference in hospitalizations for heart failure for older adults with diabetes and HbA1c of between 6% and 7%, compared with 7%-8%, among both men and women aged 71-75 and 61-65 years. In that study, investigators found that poor glycemic control (HbA1c of more than 7%) was associated with an increased risk of hospitalization for heart failure in patients with type 2 diabetes.
“This is, of course, an observational study, so we cannot draw a conclusion, but still, it strongly suggests that lower than 7% may prevent hospitalization for heart failure in elderly people.”
Glycemic variability
Another point is that HbA1c does not reflect glycemic variability, so it’s impossible to tell just from that measure the extent to which an individual is experiencing hypoglycemia – that is, two people can have the same A1c level, yet one experiences frequent hypoglycemia whereas the other never does.
“So, determining treatment based solely on A1c may be risky,” Dr. Suzuki noted.
And recently, the availability of continuous glucose monitoring is shifting the definition of “strict” glycemic control from “average” glucose to “time in range,” which also allows for a determination of the key metric “time below range.”
Recent international guidelines advise that, for older adults, fewer than 1% of readings should be below 70 mg/dL (3.9 mmol/L), compared with fewer than 4% for most other individuals with diabetes.
Thus, “in terms of avoiding hypoglycemia, older adults have a ‘stricter’ range. In other words, less stringency for high-risk people does not always mean broader allowance range in any glycemic profiles,” Dr. Suzuki noted.
However, newer drugs that don’t increase the risk for hypoglycemia are available for patients with type 2 diabetes.
Dr. Suzuki pointed to his own 2018 study demonstrating that the dipeptidyl peptidase‐4 (DPP-4) inhibitor sitagliptin had a greater ability to reduce daily glucose fluctuations in drug-naive Japanese patients with type 2 diabetes, compared with the sulfonylurea glibenclamide.
Similarly, in the Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS), the DPP-4 inhibitor did not increase severe hypoglycemia in the subgroup of participants aged 75 years and older.
And in several of the recent cardiovascular outcomes trials demonstrating cardiovascular benefit for type 2 diabetes agents, those benefits have been just as robust among older participants, he stressed.
These include the Researching Cardiovascular Events With a Weekly Incretin in Diabetes (REWIND) trial, in which those aged above and below 66 years experienced similar results with dulaglutide, a GLP-1 agonist.
And the landmark Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG OUTCOME), which actually showed even greater protection against cardiovascular events among subjects aged 65 and older (hazard ratio, 0.86).
Also in the Dapagliflozin-Heart Failure (Dapa-HF) study, the SGLT-2 inhibitor reduced worsening of heart failure in patients with heart failure with reduced ejection fraction, regardless of age or presence of diabetes.
“I argue that older patients have rights to receive appropriate and effective treatment to prevent diabetes complications,” Dr. Suzuki concluded.
Dr. Munshi is a consultant for Sanofi and Lilly. Dr. Suzuki has received honoraria from MSD, Novo Nordisk, Novartis Pharma, Takeda, Mitsubishi Tanabe, and Eli Lilly Japan.
A version of this story originally appeared on Medscape.com.
AT THE IDF CONGRESS 2019
BUSAN, SOUTH KOREA – The question of whether or not strict glycemic control is appropriate for older adults was the subject of a debate between two experts at the 2019 congress of the International Diabetes Federation.
Current guidelines from the Endocrine Society addressing diabetes management in older adults call for shared decision making and individualized approaches, taking into account comorbidities, complications, and special situations.
Medha Munshi, MD, and Ryo Suzuki, MD, PhD, took differing approaches to the risk-versus-benefit equation for older patients.
The case against ...
Dr. Munshi, director of the Joslin geriatric diabetes program at Beth Israel Deaconess Medical Center, Boston, started the debate by stating, “Yes, strict glycemic control in the elderly is meaningless.”
She based this on two main points: The benefits of strict glycemic control in older adults are not clear, and the risks are “catastrophic and well documented.”
The first problem, said Dr. Munshi, is that there is a dearth of data in older adults. In a 2013 review of 2,484 diabetes-focused studies registered on clinicaltrials.gov, just 0.6% included participants who were older than 65 years, whereas 30.8% specifically excluded that age group, and 54.9% excluded people older than 70 years.
Another analysis of 440 studies that investigated treatments for type 2 diabetes showed that, of trials that did include older adults, more than three-quarters (76.8%) excluded those with comorbidities, nearly a third (29.5%) excluded people with polypharmacy or specific drugs, and 18.4% excluded those with cognitive impairment.
“So, the trials are not targeted toward older adults, and those that are, exclude people with multiple comorbidities, so the [participants] who are left in the trials are not [representative of the patients] we see in the clinic,” Dr. Munshi emphasized.
Among the major trials that evaluated intensive treatment versus usual care in type 2 diabetes – including the UK Prospective Diabetes Study (UKPDS), the Veterans Administration Diabetes Trial (VADT), and the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial – no macrovascular benefits were found except in UKPDS, and evidence of harm was found in ACCORD.
What those trials suggested, said Dr. Munshi, is that the patients who do better with intensive glycemic control are younger, have a shorter duration of disease, fewer complications and comorbidities at baseline, better overall health, and longer life expectancy.
In contrast, those at greater risk from the hypoglycemia associated with intensive glycemic control are people who are older and frail, have longer duration of diabetes, have macro- and microvascular complications and comorbidities, are unable to safely follow complex regimens, and have shorter life expectancy.
She also pointed to a 2010 retrospective cohort study that identified a U-shaped curve relationship between hemoglobin A1c and all-cause mortality and cardiac events, suggesting that “there is a threshold beyond which, if the control is tighter, then the risk of mortality increases.”
Medications used by older adults with diabetes also pose risks, as shown in a study published in 2011 of 99,628 emergency hospitalizations for adverse drug events among U.S. adults aged 65 years and older conducted during 2007-2009.
In that study, warfarin topped the list, but insulin was the second most common, and oral hypoglycemic agents were also in the top 5.
And those episodes of emergency hospitalization, another study found, were associated with a 3.4-fold increased risk for 5-year mortality.
“ It increases the risk of cognitive decline, depression, frailty, falls and fractures, functional decline, anxiety, and fear of hypoglycemia; and it lowers quality of life,” Dr. Munshi explained.
Other unintended consequences of strict glycemic control in older adults include difficulty coping with complex regimens, increased caregiver burden, loss of independence, and increased financial burden, she added.
Control in healthy adults
A valid question, Dr. Munshi said, is whether strict glycemic control might be appropriate for older adults who are still healthy.
She responded to that by explaining that there is a phenomenon of aging called homeostenosis, a physical limit beyond which homeostasis cannot be restored in the presence of stressors, such as hypoglycemia leading to a fall, hospitalization, delirium, and poor outcome.
Another reasonable question, she added, was whether strict glycemic control in older adults could be achieved more safely and with greater benefit by using newer agents with lower risks for hypoglycemia that have been found to have cardiovascular and renal benefits.
To that, she noted that it’s not clear whether those benefits are a result of glycemic control, that the duration of the trials has been short (2-3 years), and drug interactions and side effects in populations with multiple morbidities have not been studied. Moreover, “cost and availability need consideration,” she said.
And so, she concluded, “Is strict glycemic control in the elderly really worth the risk? My answer would be no.”
The case for ...
Dr. Suzuki, a professor in the division of diabetes, metabolism, endocrinology, rheumatology, and collagen diseases at Tokyo Medical University, argued that strict glycemic control in the elderly is not “meaningless.”
He began by pointing out that his country, Japan, is “one of the most highly aging societies in the world.”
His arguments were based on three points: The elderly population is “full of diversity;” HbA1c is “not a perfect marker of glycemic control;” and new glucose-lowering drug classes may have benefits beyond reduction of blood glucose levels.
He also noted that there is no consensus on the definition of “elderly.”
Most developed countries use age 65 years and older as the cut-off, but the United Nations defines being elderly as 60 years and older, whereas the International Diabetes Federation’s guideline for managing older people with type 2 diabetes, uses 70 and older. These differences, he asserted, emphasize “the difficulty to generalize the gap between calendar age and biological age.”
Dr. Suzuki also pointed out that the American Diabetes Association’s Standards of Medical Care in Diabetes 2019 does not mention age as a consideration in individualizing glycemic targets.
Instead, factors such as risk for hypoglycemia, disease duration, life expectancy, comorbidities, established vascular complications, patient preference, and resources/support systems are listed. “We need to evaluate and assess these factors individually for every patient,” he asserted.
“Older age is very heterogeneous. Some people are very robust and active, while others are sick and frail ... We need to be careful about the active, healthy people because sometimes they need more intensified treatment to prevent complications of diabetes.”
Dr. Suzuki also pointed out that people hold important positions that require good health well into their 60s and 70s. “In many countries, many older individuals with or without diabetes have responsibilities and play important roles in their societies. Diabetes can be a big barrier for them ... Sometimes it requires hospitalizations, and they need to stop business.”
He cited an observational study from a Swedish national database showing a significant difference in hospitalizations for heart failure for older adults with diabetes and HbA1c of between 6% and 7%, compared with 7%-8%, among both men and women aged 71-75 and 61-65 years. In that study, investigators found that poor glycemic control (HbA1c of more than 7%) was associated with an increased risk of hospitalization for heart failure in patients with type 2 diabetes.
“This is, of course, an observational study, so we cannot draw a conclusion, but still, it strongly suggests that lower than 7% may prevent hospitalization for heart failure in elderly people.”
Glycemic variability
Another point is that HbA1c does not reflect glycemic variability, so it’s impossible to tell just from that measure the extent to which an individual is experiencing hypoglycemia – that is, two people can have the same A1c level, yet one experiences frequent hypoglycemia whereas the other never does.
“So, determining treatment based solely on A1c may be risky,” Dr. Suzuki noted.
And recently, the availability of continuous glucose monitoring is shifting the definition of “strict” glycemic control from “average” glucose to “time in range,” which also allows for a determination of the key metric “time below range.”
Recent international guidelines advise that, for older adults, fewer than 1% of readings should be below 70 mg/dL (3.9 mmol/L), compared with fewer than 4% for most other individuals with diabetes.
Thus, “in terms of avoiding hypoglycemia, older adults have a ‘stricter’ range. In other words, less stringency for high-risk people does not always mean broader allowance range in any glycemic profiles,” Dr. Suzuki noted.
However, newer drugs that don’t increase the risk for hypoglycemia are available for patients with type 2 diabetes.
Dr. Suzuki pointed to his own 2018 study demonstrating that the dipeptidyl peptidase‐4 (DPP-4) inhibitor sitagliptin had a greater ability to reduce daily glucose fluctuations in drug-naive Japanese patients with type 2 diabetes, compared with the sulfonylurea glibenclamide.
Similarly, in the Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS), the DPP-4 inhibitor did not increase severe hypoglycemia in the subgroup of participants aged 75 years and older.
And in several of the recent cardiovascular outcomes trials demonstrating cardiovascular benefit for type 2 diabetes agents, those benefits have been just as robust among older participants, he stressed.
These include the Researching Cardiovascular Events With a Weekly Incretin in Diabetes (REWIND) trial, in which those aged above and below 66 years experienced similar results with dulaglutide, a GLP-1 agonist.
And the landmark Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG OUTCOME), which actually showed even greater protection against cardiovascular events among subjects aged 65 and older (hazard ratio, 0.86).
Also in the Dapagliflozin-Heart Failure (Dapa-HF) study, the SGLT-2 inhibitor reduced worsening of heart failure in patients with heart failure with reduced ejection fraction, regardless of age or presence of diabetes.
“I argue that older patients have rights to receive appropriate and effective treatment to prevent diabetes complications,” Dr. Suzuki concluded.
Dr. Munshi is a consultant for Sanofi and Lilly. Dr. Suzuki has received honoraria from MSD, Novo Nordisk, Novartis Pharma, Takeda, Mitsubishi Tanabe, and Eli Lilly Japan.
A version of this story originally appeared on Medscape.com.