Diabetes and aging Robert Lash, M.D.
Old news: there’s a diabetes epidemic 8 25 7 Percentage with Diabetes Number with Diabetes (Millions) 20 Number with Diabetes Percentage with Diabetes 6 5 15 4 10 3 2 5 1 0 0 1958 61 64 67 70 73 76 79 82 85 88 91 94 97 00 03 06 09 11 Year CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
85% 85% of of pa patien tients ts ar are di diagnosed agnosed af after ter the they turn turn 40 40 http://www.cdc.gov/diabetes/statistics/age/fig1.htm
Why is Wh is diabe diabetes es mor more co common mmon as as we we ag age? e? AGING, March 2014, Vol. 6 No.3
The The re result – a – a lot lot of of older older Am Americ ericans ans ha have diabe diabetes es 30 Percentage of patients with diabetes 25 20 15 10 5 0 20 ‐ 44 45 ‐ 64 65 or older
Ar Areas eas of of co concern fo for ol older der pa patien tients ts • Glucose control targets • Treatment choices (and avoiding hypoglycemia) • Treating cholesterol and hypertension • Complication screening • Foot care
Gl Glycemi emic co cont ntrol co considerat ations Hypoglycemia Good functional status Shorter life expectancy Life expectancy > 10 years Comorbidities/disabilities Short duration of diabetes Fall risk/functional impairment Minimal comorbidities Polypharmacy A1c < 7.5% A1c < 8.0% A1c < 8.5% Fasting glucose 140 ‐ 150 mg/dL Fasting glucose 160 ‐ 170 mg/dL Average glucose ~200 mg/dL
Trea eatm tmen ent choices choices (and (and av avoiding hy hypoglycemia) Pre ‐ 1995 Post ‐ 1995 • Insulin • Metformin • Sulfonylureas • Disaccharidase inhibitors • GLP ‐ 1 agonists • DPP ‐ IV inhibitors • SGLT2 inhibitors • (Bromocriptine)
Trea eatm tmen ent choices choices (and (and av avoiding hy hypoglycemia) Weight gain Weight loss or neutral • Insulin • Metformin • Sulfonylureas • Disaccharidase inhibitors • GLP ‐ 1 agonists • DPP ‐ IV inhibitors • SGLT2 inhibitors • (Bromocriptine)
Trea eatm tmen ent choices choices (and (and av avoiding hy hypoglycemia) Risk of hypoglycemia No hypoglycemia • Insulin • Metformin • Sulfonylureas • Disaccharidase inhibitors • GLP ‐ 1 agonists • DPP ‐ IV inhibitors • SGLT2 inhibitors • (Bromocriptine)
Emergency Hospitalizations for Adverse Drug Events in Older Americans Budnitz DS, et. al. NEJM. 365:2002 ‐ 12. (2011)
Hypoglycemia is a frequent cause of drug ‐ related emergency hospitalizations Budnitz DS, et. al. NEJM. 365:2002 ‐ 12. (2011)
A Systematic Review and Meta-Analysis of Hypoglycemia and Cardiovascular Events A comparison of glyburide with other secretagogues and with insulin Ganji AS, Cukierman T, Gerstein HC, et. al. Diabetes Care 30:389–394 (2007)
Glyburide causes more hypoglycemia than other sulfonylureas All Major Any hypoglycemia hypoglycemia Comparator hypoglycemia (per patient- (per patient- CV events Death year) year) Sulfonylureas 1.83 1.44 4.7 0.92 (0.71- 0.79 (1.35-2.49) (1.13-1.85) (0.78-28.1) 1.19) (0.47-1.32) Insulin 0.88 (0.25- 0.09 0.89 0.97 3.06) (0.02-0.41) ND (0.7-1.14) (0.79-1.20) Ganji AS, et. al. Diabetes Care 30:389–394 (2007)
Tr Treating choles cholesterol and and hy hypertension • Cholesterol • Statins remain a good idea • Reduce risk of CV events in patients with diabetes, regardless of starting LDL • This year’s controversy: should there (once again) be LDL targets? • Hypertension • Hypertension is more common as we age • Most ‘bang for the buck’ in reducing CV risk • This year’s controversy: what treatment goal should we pick?
Compl Complicati tion on scr screening eening • Eye exams • Should still be yearly for most patients • Glaucoma and cataracts are more common in patients with diabetes • Screening for kidney involvement • Yearly, unless patient is already on an ACE or an ARB • Coronary artery disease • Check LDL • Ask about anginal symptoms, and listen carefully • It’s never too late to stop smoking
• Diabetes is the number one cause of non ‐ traumatic foot amputations • 50% of older patients with diabetes have neuropathy • 30% of older patients with diabetes can’t see or reach their feet • Feet should be examined at every visit, and home foot care reviewed • Low threshold for referral to podiatry
Things Things to to re reme memb mber if if yo you’re re jus just wa waking up up • One ‐ quarter of older Americans have diabetes • Their treatment targets depend on their health and life expectancies • Try to avoid hypoglycemia • Don’t forget about treating hypertension and cholesterol • Complication screening is still important • Foot care is often overlooked. . . and shouldn’t be
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