rational goal-setting and management of diabetes in the elderly · 2018. 10. 30. · standing...
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Rational Goal-Setting and Management
of Diabetes in the Elderly
Michael Shannon, MD
Medical Director, Physicians of Southwest Washington
Clinical Assistant Professor, University of Washington
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Outline of Talk
Challenges of diabetes care in the elderly
Goal setting and A1c targets in elderly
Review of treatment options for elderly with
review of classes
Tools for older patients with specific needs:
grip, vision, memory, newer technology
Disclosure: Speaker and Consultant, Novo Nordisk
and BI/Lilly Alliance
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Epidemiology of Diabetes in Elderly
Estimated at 26% for those aged 65+
Long term care (2007-13): multiple studies
cite 25-34% in LTC facilities (SNF and ALF)
Several Challenges in Managing These Patients
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Hypoglycemia in the Elderly
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Hypoglycemia in the Elderly
Psychomotor coordination deteriorates earlier
and greater in elderly erasing the usual 10–20
mg/dL difference between subjective
awareness and onset of cognitive dysfunction
Hypoglycemia recognized in far fewer elderly
Presentation overlaps other frailty syndromes
Confusion, word-finding errors, altered LOC
Tremors / dizziness
No one goes wrong getting a UA and Fingerstick
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Hypoglycemia in the Elderly
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Hypoglycemia in the Elderly
Hypoglycemia and cognitive impairment have
partial bidirectional relationship
Severe hypoglycemia linked to cognitive
impairment
Cognitive impairment increases hypoglycemia risk
Hypoglycemia increases risk of falls and
fractures (neuroglycopenic symptoms…)
Probably increases placement rates
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Hypoglycemia in the Elderly
Limited ability to self-manage hypoglycemia
Limited vision/transfer ability to self-rescue
Increased fall risk, sedation from other medication
In institution, limited access to self-correction
Glucagon probably underutilized – arrival of
nasal glucagon will help caregivers of elderly
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Hyperglycemia in the Elderly
Symptomatic hyperglycemia
Polyuria: glycosuria load, UTI risk
Dehydration (impaired thirst, impaired access)
Blurry vision (increased falls)
Impaired wound healing
Unlike hypoglycemia, these are more subtle
and slower to emerge -> need more vigilance
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Polypharmacy and Complex PMH
Increases Hyperglycemia
Steroids
Antipsychotics
Infections / immobility
Increases Hypoglycemia
Sedative Agents (Alcohol)
Renal impairment
Poor nutrition
Cirrhosis (limited synthesis)
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Diabetes Assessment in the Elderly
Goal-Setting for General Diabetes Plan
Physical Assessment
Nutritional Assessment
Physical Assessment
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12
Nutritional Assessment
Malnutrition
Poverty / isolation
Dentition
WWII Widower
Depression
Cognitive Impairment
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13
Physical Assessment
Ophthalmic
Higher rates of cataracts, glaucoma and macular
degeneration.
Dexterity/Hands:
Vials vs pens, choice of meters
General Home Safety Eval (cords, rugs, cats)
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Diabetes Goals in the Elderly
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Standards of
Medical Care in
Diabetes - 2018
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A1C Goals in Adults: Recommendations (2)
• Less stringent goals (such as <8% [64 mmol/mol]) may
be appropriate for patients with a history of severe
hypoglycemia, limited life expectancy, advanced
microvascular or macrovascular complications, or long-
standing diabetes in whom the goal is difficult to achieve
despite diabetes self-management education,
appropriate glucose monitoring, and effective doses of
multiple glucose-lowering agents including insulin. B
Glycemic Targets:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S55-S64
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Approach to the Management of Hyperglycemia
low high
newly diagnosed long-standing
long short
absent severeFew/mild
absent severeFew/mild
highly motivated, adherent, excellent self-care capabilities
readily available limited
less motivated, nonadherent, poor self-care capabilities
A1C
7%more
stringent
less
stringentPatient/Disease Features
Risk of hypoglycemia/drug adverse effects
Disease Duration
Life expectancy
Important comorbidities
Established vascular complications
Patient attitude & expected
treatment efforts
Resources & support system
Glycemic Targets:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S55-S64
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Elderly DM Goals: My 3 Levels
For those with good functional status, same as
others post-ACCORD study (probably about
7.5% depending on CV disease)
For life expectancy ~5 years, < 8% or 8.5%
(weigh comorbidities, functional status, goals)
For palliative care patients: avoid symptoms
Glucose > 180 = glycosuria, dehydration, UTIs
Glucose over ~225 = poor wound healing,
increased decubitus ulcers
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Diabetes: CV Outcome Trials
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Landmark CV Trials for Elderly DM
DCCT: For DM1, enrolled people < 39 years of age
UKPDS: did not enroll past 59 years of age
Last round of trials without CV benefit include
ACCORD (mean age 62), VADT (mean age 60), and
ADVANCE (mean age 66) but few > 75 years old
No outcome trial focused on elderly (no HYVET)
No major trials at all for frail/institutionalized elderly
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Pharmacologic Approaches to Glycemic Treatment:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S73-S85
ADA 2018: Pharmacologic
Therapy For DM2 and ASCVD
Lifestyle management and metformin
Subsequently, incorporate an agent proven to reduce
major adverse CV events and mortality (currently
empagliflozin and liraglutide) considering drug and
patient factors (Level A)
Canagliflozin may be considered (Level C)
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EMPA REG by Age
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LEADER - Analysis by Age
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CANVAS – Analysis by Age
Neal B, et al. N Engl J Med. 2017;377:644-657.
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Diagnosis is a fairly soft endpoint,
but death is unequivocal.
Edwin AM Gale, Lancet 2003
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The Diabetes Toolbox 2018
Drug Class (First in Class) FDA Approval
Insulin (subcutaneous) 1922 (first use)
Sulfonylurea (chlorpropamide) 1958
Biguanide (metformin) 1995
Alpha-glucosidase inhibitors (acarbose) 1995
Thiazolidinedione (troglitazone) 1997
Meglitinide (repaglinide) 1997
Incretins (pramlintide, exenatide) 2005
DPP-IV Inhibitors (sitagliptin) 2006
Bile acid sequestrant (colesevelam) 2008 (DM)
Dopamine agonist (bromocriptine QR) 2009
SGLT-2 inhibitor (canagliflozin) 2013
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The Toolbox in 2018
Metformin: great – with new GFR guidance –
please use metformin ER
Sulfonylureas: cheap, but risk of
hypoglycemia; no more glyburide (and its evil
metabolite norglyburide cleared through
kidneys) -> now $4 monthly glimepiride
TZDs: no hypoglycemia but risks of edema,
CHF, and possibly fractures and malignancies
Available for Q&A: colesevelam, bromocriptine
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Metformin
FDA (April 2016): “We have concluded
from the review of studies published in the
medical literature that metformin can be
used safely in patients with mild impairment
in kidney function and in some patients with
moderate impairment in kidney function.”
Label update: now “contraindicated” if
eGFR is <30mL/min/1.73m2
2014 update from the International Society
of Nephrology: metformin may still be
appropriate for eGFR 14-29mL/min/1.73m2
if kidney disease is stable
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GLP-1 Agonists
Modest benefit in HbA1c 0.7-1.1% and some
weight loss as well but some nausea
Safety warnings about pancreatitis and
medullary thyroid cancer
Cardiovascular studies complete for several
Can be used in combination with basal insulin
at same time of day, for probably best efficacy
with reasonably low risk of hypoglycemia
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DPP-IV Inhibitors
Sitagliptin, saxagliptin, linagliptin, alogliptin
Modest decrease in HbA1c of 0.5% - 0.8%;
Minimal side effects (possible more minor
infections) except saxagliptin showed increased
congestive heart failure (seen in ADA guideline)
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SGLT-2 Inhibitors
Approved starting in 2013; blocks renal re-
absorption of glucose and lowers blood sugars
Associated with similar modest HbA1c decrease
of 0.5% - 0.7%) as DPP-IV inhbitors (UTDOL)
Risks: infections and dehydration, DKA
Independent of resistance (can use with insulin)
but limit dose eGFR 45-60 and don’t use <
eGFR 45 or with hepatic impairment
CV Studies: EMPA REG, CANVAS
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Final Words on Newer Agents
None of these have been in wide use for long
Lessons of rosiglitazone: hemoglobin A1c is
a surrogate endpoint, not the true goal of care
All the new drugs cost upwards of $10/day
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Final Words on Newer Agents
None of these have been in wide use for long
Lessons of rosiglitazone: hemoglobin A1c is
a surrogate endpoint, not the true goal of care
All the new drugs cost upwards of $10/day
For elderly, hypoglycemia safety probably is
main reason to use, or dosing convenience,
with possible exception of empagliflozin and
liraglutide b/c cardiovascular outcome study
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Indications for Insulin Therapy
Severe hyperglycemia at diagnosis
Hyperglycemia despite maximum doses of
non-insulin agents
Decompensation of other organ systems that
limits use of other oral agents
Early potent treatment with safety other than
hypoglycemia
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Combination Injectable Therapy in T2DM
Pharmacologic Approaches to Glycemic Treatment:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S73-S85
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The Medicare Test Strip Quandry
1-2 tests/day x 12 weeks, 6 tests/day x 1 week w notes
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Tools for Limited Sight/Grip
Insulin Pens = KEY for many elderly
Much easier to get nowadays, somewhat more $
Occupational therapist may be able to help grip
Certain meters good for low vision
Prodigy Voice: endorsed by AFB, NFB
FORA series
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Tools for Limited Memory
For oral meds: mediset or blister packs
Once weekly GLP1 may be a tool for those
with VNS and/or family member
Newer meters with memory function:
Echo, Memoir, and Timesulin cap
Newer “smart pens” integrated with software
Intensive insulin may require higher level of
placement (DM1, wound issues, etc)
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To Infinity and Beyond
Insulin Pens = KEY for elderly (easier than
ever: CTS, visual impairment, neuropathy)
Insulin pumps appropriate if motivated and
fulfill strict Medicare criteria
Continuous monitors approved for Medicare
specific to two compan – work in progress
AMDA has excellent LTC guidelines for also
incorporating multidiscipinary team
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Conclusion
Diabetes is common in the elderly and care of
these individuals is more challenging
ADA and AACE have slightly different goals
of care and toolbox can be viewed with focus
on elderly
The EMPA REG and LEADER study showed
cardiovascular and all-cause mortality
reduction with empagliflozin and liraglutide
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Questions and Appreciation