Use of Intensive Glycemic Management in Older Adults with Diabetes Mellitus

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Abstract

Tight glucose control reduces microvascular complications at the cost of an increased risk of hypoglycemia. Guidelines recommend conservative management for older adults with diabetes, particularly in the setting of comorbidities. We examined the proportion of older adults with diabetes treated with tight glucose control and the factors associated with this practice. Cross-sectional analysis of 42,669 adults ≥75 years of age with type 2 diabetes from 151 US outpatient sites in the Diabetes Collaborative Registry. Patients were categorized based on HbA1c and glucose-lowering medications: poor control (HbA1c >9%), moderate control (HbA1c >8–9%), conservative control (HbA1c 7–8%), tight control (HbA1c <7%) with low-risk agents (low risk for hypoglycemia), tight control with high-risk agents, and diet control (HbA1c <7% on no glucose-lowering medications). We used hierarchical logistic regression to examine patient and site factors associated with tight control/high-risk agents vs. conservative control or tight control/low-risk agents. Among 30,696 patients without diet controlled diabetes, 5,596 (18%) had moderate or poor control, 9,227 (30%) had conservative control, 7,893 (26%) had tight control on low-risk agents, and 7,980 (26%) had tight control on high-risk agents. Older age, male sex, heart failure, chronic kidney disease, and coronary artery disease were each independently associated with a greater odds of tight control with high-risk agents. There were no differences among practice specialties (endocrinology, primary care, cardiology) in how aggressively the patients were managed. We found that a quarter of US older adults with type 2 diabetes are tightly controlled with glucose-lowering medications that have a high risk of hypoglycemia. These results suggest potential overtreatment of a substantial proportion of patients and should encourage further efforts to translate guidelines to daily practice.

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Individualizing glycemic targets in type 2 diabetes mellitus: implications of recent clinical trials.

Etie Moghissi, Saul Genuth, Margaret Tiktin … (2011)

One of the first steps in the management of patients with type 2 diabetes mellitus is setting glycemic goals. Professional organizations advise setting specific hemoglobin A(1c) (HbA(1c)) targets for patients, and individualization of these goals has more recently been emphasized. However, the operational meaning of glycemic goals, and specific methods for individualizing them, have not been well-described. Choosing a specific HbA(1c) target range for a given patient requires taking several factors into consideration, including an assessment of the patient's risk for hyperglycemia-related complications versus the risks of therapy, all in the context of the overall clinical setting. Comorbid conditions, psychological status, capacity for self-care, economic considerations, and family and social support systems also play a key role in the intensity of therapy. The individualization of HbA(1c) targets has gained more traction after recent clinical trials in older patients with established type 2 diabetes mellitus failed to show a benefit from intensive glucose-lowering therapy on cardiovascular disease (CVD) outcomes. The limited available evidence suggests that near-normal glycemic targets should be the standard for younger patients with relatively recent onset of type 2 diabetes mellitus and little or no micro- or macrovascular complications, with the aim of preventing complications over the many years of life. However, somewhat higher targets should be considered for older patients with long-standing type 2 diabetes mellitus and evidence of CVD (or multiple CVD risk factors). This review explores these issues further and proposes a framework for considering an appropriate and safe HbA(1c) target range for each patient.

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Rates of Deintensification of Blood Pressure and Glycemic Medication Treatment Based on Levels of Control and Life Expectancy in Older Patients With Diabetes Mellitus.

Jeremy Sussman, Eve Kerr, Sameer Saini … (2015)

Older patients with diabetes mellitus receiving medical treatment whose blood pressure (BP) or blood glucose level are potentially dangerously low are rarely deintensified. Given the established risks of low blood pressure and blood glucose, this is a major opportunity to decrease medication harm.