Management of DM in Older Adults: It s not all about sugar! Who needs treatment for DM? Peggy Odegard, Pharm.D., BCPS, CDE

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1 Management of DM in Older Adults: It s not all about sugar! Peggy Odegard, Pharm.D., BCPS, CDE Who needs treatment for DM? 87 year old, frail male with moderately severe dementia living in NH with persistent and problematic leg pain 92 year old, healthy female living independently at home with severe osteoporosis 62 year old, debilitated male living at home with hypertension, hyperlipidemia, arthritis, recent diagnosis of advanced prostate cancer At the end of this discussion, the learner should Understand the physiologic basis for treatment of DM in older adults Know the AGS expert panel recommendations for treatment and goals for control of DM in older adults Know the pharmacokinetic, pharmacodynamic, and pharmacologic considerations for the use of medications in older adults with DM Be able to prioritize DM tx based on risk/benefit 1

2 The three main points 1. Blood glucose management in older adults with DM must address post-prandial hyperglycemia along with FPG and A1c 2. DM management in older adults must address the combined risks of DM and aging including CV disease, stroke, and geriatric syndromes 3. DM management in older adults must be individualized based on the tx benefit related to life expectancy, frailty, and comorbid conditions/drugs Point #1 Blood glucose management in older adults with DM must address post-prandial hyperglycemia along with FPG and A1c In general terms, older adults with DM diagnosed in middle age may have insulin resistance as the primary DM process causing or mixed with some degree of pancreatic dysfunction diagnosed in older age may have pancreatic dysfunction as the primary DM process who are ideal weight at diagnosis, may be experiencing pancreatic dysfunction or failure usually experience some degree of post-prandial hyperglycemia 2

3 Point #2 DM management in older adults must address the combined risks of DM and aging including CV disease, stroke, and geriatric syndromes Associated Risks of Aging Increased risk for Cardiovascular disease Polypharmacy* Depression* Cognitive Impairment* Urinary Incontinence* Falls* Macular degeneration Persistent Pain* * common geriatric syndromes What does this mean for DM management? It is more than just correcting blood glucose Increased blood pressure can hasten development and progression of kidney, nerve, heart, and eye damage from hyperglycemia The choice of DM medications may be affected by comorbid conditions Heart and brain health need to be promoted The treatment plan should be individualized! 3

4 Summary: AGS goals for tx in older adults Physiologic Parameter Blood glucose (A1c) Goal Healthy: <7% Frail: <8% Lipids: LDL Lipids: HDL Lipids: triglycerides Blood Pressure < 100 mg/dl >40 mg/dl > 150 mg/dl <140/80 mmhg although <130/80 may provide further benefit JAGS 2003;51(5) S265-S280 What treatments must be considered for DM in older adults? Lifestyle modification Smoking cessation if indicated Weight reduction Increased physical activity Blood glucose Hypoglycemic or antiglycemic agents Heart Aspirin Lipid lowering agent Antihypertensive agent Kidneys ACEI or ARB Antidepressant tx if indicated Management or prevention of geriatric syndromes Another way to look at it ABCs of DM A=A1c normalization without placing patient at too great a risk of hypoglycemia B=Blood Pressure Control at <130/<80 if possible C=Cholesterol (LDL < 100 mg/dl) 4

5 Point #3 DM management in older adults must be individualized based on the tx benefit related to life expectancy, frailty, and comorbid conditions/drugs How long to see treatment benefits? Physiologic Parameter Lipids Blood pressure Blood glucose Time to see benefit of tx 2-3 years 2-3 years 8 years Outcome Reduced stroke and MI morbidity and mortality Reduced stroke and MI morbidity and mortality Reduced microvascular disease Reduced CV dx 5

6 Approach to DM tx in older adults Assess individual DM risks and identify opportunities for risk reduction Initiate meal planning and recommend increased activity, if appropriate. Metformin if insulin resistance and adequate CrCl. If hyperglycemia symptoms or concern (e.g. >300 mg/dl), move to DM drug tx. Initiate smoking cessation, if appropriate daily aspirin, if not contraindicated improved BP control, if needed lipid lowering, if needed Reassess in 3-6 months Approach to DM tx in older adults During the initial 3-6 month treatment period, evaluate DM drug therapy options based on blood glucose results (highs versus lows?) labs (liver, kidney function) med history (allergies?) insulin resistance (abdominal obesity?, sedentary?) patient preferences and abilities Add pharmacotherapy If no appreciable response of bg or A1c in 3-6 months of lifestyle adjustment, initiate drug tx Overweight? Signs of insulin resistance? yes no Consider need to modify insulin resistance and improve glucose utilization: Metformin? OR Glitazone? CHF, Hepatic or renal dysfunction Consider pancreatic dysfunction: Sulfonylurea? OR Insulin? If post-prandial glucoses remain elevated, modify meals (carb intake!) or consider α- glucosidase inhibitor or glinide If pancreatic failure is worsening, initiate insulin as early as possible 6

7 Pharmacodynamic Considerations Screen for drug-induced causes or worsening of hyperglycemia Thiazide diuretics Corticosteroids (systemic or high dose inhaled) Atypical antipsychotics niacin Prevent drug-induced injury or illness Avoid agents increasing risks such as falls, cognitive decline, memory impairment Monitor appropriately Serum potassium and renal function should be monitored within 1-2 weeks of starting an ACEI or ARB, with dose increases, and annually Provide education to reduce risk (e.g. falls) Pharmacodynamic Considerations Glitazone-associated fluid retention may be a risk for CHF worsening or more prominent side effect in older adults Risk for hypoglycemia increases with age Impaired glucagon secretion Altered autonomic response Beta blockers may blunt the person s ability to sense the sympathetic response to hypoglycemia (shaking, anxiousness) Pharmacokinetic Considerations Start low, go slow!!! Use of drugs with long half-life or metabolism to active metabolites may lead to increased risk of hypoglycemia Chlorpropamide (avoid use half life hours with normal renal and hepatic function!) Glyburide (half-life 5-16 hours versus 2-4 hours for glipizide) Use of short-onset/short-acting insulin analogs may reduce risk of post-prandial hypoglycemia associated with regular insulin The clearance of renally eliminated drugs may be reduced in older adults Metformin (avoid use if Scr >1.5 men or >1.4 mg/dl women, CrCl less than normal, or age >80 unless ok CrCl) Insulin 7

8 Pharmacologic Considerations Isolated post-prandial hyperglycemia (if carbs/calorie intake not a precipitating factor) consider repaglinide, nateglinide, or shortacting insulin Isolated fasting hyperglycemia consider metformin Pancreatic dysfunction, to some extent, is usually present in older adults with DM consider insulin or insulin secretagogue (e.g. sulfonylurea) Pharmacologic Considerations Hyperglycemia throughout the day (with adequate carb/calorie intake) may indicate worsening pancreatic function Consider insulin secretagogue or try insulin (don t wait!) Reduce medication dose if frequent (daily) or severe (needs assistance) hypoglycemia in face of no identifiable cause (e.g. inadequate intake, overdose) Combination tx often needed for diabetes and hypertension Summary Prevention of DM should be encouraged whenever possible through lifestyle modification this is especially helpful in older adults Blood glucose management in older adults with DM must address post-prandial hyperglycemia along with FPG and A1c DM management in older adults must address the combined risks of DM and aging including CV disease, stroke, and geriatric syndromes DM management in older adults must be individualized based on the tx benefit related to life expectancy, frailty, and comorbid conditions/drugs Tx to standard targets if health status good Tx to modified targets if frail or benefit is not clear 8