Rational Goal-Setting and Management of Diabetes in the Elderly

Transcription

1 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

2 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

3 Epidemiology of Diabetes in Elderly Estimated at 26% for those aged 65+ Long term care ( ): multiple studies cite 25-34% in LTC facilities (SNF and ALF) Several Challenges in Managing These Patients

4 Hypoglycemia in the Elderly

5 Hypoglycemia in the Elderly Psychomotor coordination deteriorates earlier and greater in elderly erasing the usual 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

6 Hypoglycemia in the Elderly

7 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

8 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

9 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

10 Polypharmacy and Complex PMH Increases Hyperglycemia Steroids Antipsychotics Infections / immobility Increases Hypoglycemia Sedative Agents (Alcohol) Renal impairment Poor nutrition Cirrhosis (limited synthesis)

11 Diabetes Assessment in the Elderly Goal-Setting for General Diabetes Plan Physical Assessment Nutritional Assessment Physical Assessment

12 Nutritional Assessment Malnutrition Poverty / isolation Dentition WWII Widower Depression Cognitive Impairment 12

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) 13

14 Diabetes Goals in the Elderly

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16 Standards of Medical Care in Diabetes

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18 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 longstanding 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 Diabetes Care 2018; 41 (Suppl. 1): S55-S64

19 Approach to the Management of Hyperglycemia Patient/Disease Features Risk of hypoglycemia/drug adverse effects Disease Duration Life expectancy Important comorbidities Established vascular complications more stringent low newly diagnosed long absent absent A1C 7% Few/mild Few/mild less stringent high long-standing short severe severe Patient attitude & expected treatment efforts Resources & support system highly motivated, adherent, excellent self-care capabilities readily available Glycemic Targets: Standards of Medical Care in Diabetes Diabetes Care 2018; 41 (Suppl. 1): S55-S64 less motivated, nonadherent, poor self-care capabilities limited

20 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

21 Diabetes: CV Outcome Trials

22 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

23 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) Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes Diabetes Care 2018; 41 (Suppl. 1): S73-S85

24 EMPA REG by Age

25 LEADER - Analysis by Age

26 Neal B, et al. N Engl J Med. 2017;377: CANVAS Analysis by Age

27 Diagnosis is a fairly soft endpoint, but death is unequivocal. Edwin AM Gale, Lancet 2003

28 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

29 Available for Q&A: colesevelam, bromocriptine 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

30 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/1.73m update from the International Society of Nephrology: metformin may still be appropriate for egfr 14-29mL/min/1.73m 2

31 GLP-1 Agonists Modest benefit in HbA1c % 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

32 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)

33 SGLT-2 Inhibitors Approved starting in 2013; blocks renal reabsorption 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 and don t use < egfr 45 or with hepatic impairment CV Studies: EMPA REG, CANVAS

34 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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36 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

37 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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39 Combination Injectable Therapy in T2DM Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes Diabetes Care 2018; 41 (Suppl. 1): S73-S85

40 The Medicare Test Strip Quandry 1-2 tests/day x 12 weeks, 6 tests/day x 1 week w notes

41 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

42 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)

43 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

44 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

45 Questions and Appreciation