New guidelines for management of diabetes in Elderly: Endocrine Society

DELHI: The Endocrine Society has released new guidelines for the treatment of diabetes in older adults. The guideline, presented at the Endocrine Society Annual Meeting and simultaneously published in the Journal of Clinical Endocrinology and Metabolism, addresses the numerous complex issues involved in managing the growing population of older adults with diabetes.

"For many decades and many years, we have not really paid a lot of attention to the older individual with diabetes because they were considered to have a limited lifespan. But we now know that 65 to 70-year-olds live until 85 to 90 years, and so preventing the long-term complications is very important, much as the short-term issues they suffer from," said committee chair Derek LeRoith, of the Icahn School of Medicine at Mount Sinai, New York City, during a press briefing.

The 2019 guideline:

• Provides recommendations for older patients with diabetes and macro and microvascular co-morbidities


• Provides recommendations for the screening, diagnosis, and treatment of diabetes in older adults


• Emphasizes shared-decision making and lesser targets/goals depending on the health condition

KEY RECOMMENDATIONS

Role of the Endocrinologist and Diabetes Care Specialist

• In patients aged 65 years and older with newly diagnosed diabetes, we advise that an endocrinologist or diabetes care specialist should work with the primary care provider, a multidisciplinary team, and the patient in the development of individualized diabetes treatment goals.


• In patients aged 65 years and older with diabetes, an endocrinologist or diabetes care specialist should be primarily responsible for diabetes care if the patient has type 1 diabetes, or requires complex hyperglycemia treatment to achieve treatment goals, or has recurrent severe hypoglycemia, or has multiple diabetes complications.

Screening for Diabetes and Prediabetes, and Diabetes Prevention

• In patients aged 65 years and older without known diabetes, we recommend fasting plasma glucose and/or HbA1c screening to diagnose diabetes or prediabetes.


• In patients aged 65 years and older without known diabetes who meet the criteria for prediabetes by fasting plasma glucose or HbA1c, we suggest obtaining a 2-hour glucose post-oral glucose tolerance test measurement.

Assessment of Older Patients with Diabetes

• In patients aged 65 and older with diabetes, we advise assessing the patient's overall health and personal values prior to the determination of treatment goals and strategies.


• In patients aged 65 years and older with diabetes, we suggest that periodic cognitive screening should be performed to identify undiagnosed cognitive impairment.


• In patients aged 65 years and older with diabetes and a diagnosis of cognitive impairment, we suggest that medication regimens should be simplified and glycemic targets tailored to improve compliance and prevent treatment-related complications.

Treatment of Hyperglycemia

• In patients aged 65 years and older with diabetes, we recommend that outpatient diabetes regimens be designed specifically to minimize hypoglycemia.


• In patients aged 65 years and older with diabetes who are treated with insulin, we recommend frequent fingerstick glucose monitoring and/or continuous glucose monitoring in addition to HbA1c.


• In patients aged 65 years and older with diabetes who are ambulatory, we recommend lifestyle modification as the first-line treatment for hyperglycemia.


• In patients aged 65 years and older with diabetes, we recommend assessing nutritional status to detect and manage malnutrition.


• In patients aged 65 years and older with diabetes and frailty, we suggest the use of diets rich in protein and energy to prevent malnutrition and weight loss.


• In patients aged 65 years and older with diabetes who cannot achieve glycemic targets with lifestyle modification, we suggest avoiding the use of restrictive diets and instead limiting consumption of simple sugars if patients are at risk of malnutrition.


• In patients aged 65 years and older with diabetes, we recommend metformin as the initial oral medication chosen for glycemic management in addition to lifestyle management.


• In patients aged 65 years and older with diabetes who have not achieved glycemic targets with metformin and lifestyle, we recommend that other oral or injectable agents and/or insulin should be added to metformin.

Treating Complications of Diabetes

• In patients aged 65 to 85 years with diabetes, we recommend a target blood pressure of 140/90 mmHg to decrease the risk of cardiovascular disease outcomes, stroke, and progressive chronic kidney disease.


• In patients aged 65 years and older with diabetes and hypertension, we recommend that an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker should be first-line therapy.


• In patients aged 65 years and older with diabetes, we recommend an annual lipid profile.


• In patients aged 65 years and older with diabetes, we recommend statin therapy and the use of an annual lipid profile to achieve the recommended levels for reducing absolute cardiovascular disease events and all-cause mortality.


• In patients aged 65 years and older with diabetes, we suggest that if statin therapy is inadequate for reaching the LDL-C reduction goal, either because of side effects or because the LDL-C target is elusive, then alternative or additional approaches should be initiated.


• In patients aged 65 years and older with diabetes and fasting triglycerides >500 mg/dL, we recommend the use of fish oil and/or fenofibrate to reduce the risk of pancreatitis.


• In patients aged 65 years and older who have diabetes and congestive heart failure, we advise treatment in accordance with published clinical practice guidelines on congestive heart failure.


• In patients aged 65 years and older who have diabetes and congestive heart failure, the following oral hypoglycemic agents should be prescribed with caution in order to prevent worsening of heart failure:
  
  
  
  • Glinides
  
  
  • Rosiglitazone
  
  
  • Pioglitazone
  
  
  • DPP4 inhibitors
  
  
  
  


• In patients aged 65 years and older with diabetes and a history of atherosclerotic cardiovascular disease, we recommend low-dosage aspirin (75-162 mg/day) for secondary prevention of cardiovascular disease after careful assessment of bleeding risk and collaborative decision-making with the patient, family, and other caregivers.


• In patients aged 65 years and older with diabetes, we recommend annual comprehensive eye exams to detect retinal disease.


• In patients aged 65 years and older with diabetes and peripheral neuropathy with balance and gait problems, we suggest referral to physical therapy or a fall management program to reduce the risk of fractures and fracture-related complications.

Management of Diabetes Away from Home – in Hospitals and Long-term Care Facilities – and Transitions of Care

• In patients aged 65 years and over with diabetes in hospitals or nursing homes, we recommend establishing clear targets for glycemia at 100–140 mg/dL (5.55–7.77 mmol/L) fasting and 140–180 mg/dL (7.77–10 mmol/L) postprandial while avoiding hypoglycemia.


• In patients aged 65 years and older with diabetes and a terminal illness or severe comorbidities, we recommend simplifying diabetes management strategies.


• In patients aged 65 years and older without diagnosed diabetes, we suggest routine screening for HbA1c during admission to the hospital to ensure detection and treatment where needed.

For detailed recommendations follow the links: https://doi.org/10.1210/jc.2019-00198 and https://www.endocrine.org/2019diabetes