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Management of Diabetes in the Older Person

This workshop discusses the benefits of tight glycemic control in older individuals with diabetes, guidelines for treatment and drug selection, and the prevention of complications. Topics include hypoglycemia, cognitive decline, frailty, and mobility limitations.

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Management of Diabetes in the Older Person

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  1. Management of Diabetes in the Older Person Nicola Zammitt CD ECED Secondary care lead Diabetes MCN 30/3/17

  2. Outline of workshop • What are the benefits of tight glycaemic control? • Is tight glycaemic control a bad thing? • What will make a difference to life expectancy? • Are there guidelines/targets for older people? • Which drugs should we choose? • What else would anyone like to discuss?

  3. Benefits of tight glycaemic control • Relief of symptoms • Reduction of complications UKPDS 33 Lancet 1998

  4. Benefits of tight glycaemic control • Relief of symptoms • Reduction of complications UKPDS 33 Lancet 1998 Time since randomisation (yrs) 0 3 6 9 12 15

  5. Benefits of tight glycaemic control • Relief of symptoms • Reduction of complications UKPDS 33 Lancet 1998 Time since randomisation (yrs) 0 3 6 9 12 15

  6. Benefits of tight glycaemic control • Relief of symptoms • Reduction of complications UKPDS 33 Lancet 1998

  7. Benefits of tight glycaemic control • Relief of symptoms • Reduction of complications UKPDS 10 yr FU NEJM 2008

  8. Benefits of tight glycaemic control • Relief of symptoms • Reduction of complications UKPDS 10 yr FU NEJM 2008

  9. Benefits of tight glycaemic control • Relief of symptoms • Reduction of complications UKPDS 10 yr FU NEJM 2008

  10. Benefits of tight glycaemic control • Relief of symptoms • Reduction of complications UKPDS 10 yr FU NEJM 2008

  11. Benefits of tight glycaemic control • Relief of symptoms • Reduction of complications UKPDS 10 yr FU NEJM 2008 Loss of HbA1c between-group differences “Legacy effect” ? Benefits of early control

  12. Benefits of tight glycaemic control • Relief of symptoms • Reduction of complications • Evidence of benefit for microvascular disease • ? Legacy effect for macrovascular disease • Long time to see benefits (espmacrovascular) • Patient age • Comorbidities • What complications are we trying to prevent?

  13. Hypoglycaemia in type 2 DM • Risk of hypo increases with increasing insulin deficiency and duration of insulin treatment • Regardless of treatment modality, intensive therapy associated with increased risks of hypo • Insulin-deficient patients with T2DM can develop syndromes such as IHA and HAAF • IHA increases risk of SH. • Older patients are at increased hypo risk as a result of diminished symptoms and altered thresholds for counterregulatory responses • Knowledge of hypoglycaemia is poor in the elderly and their relatives

  14. Hypoglycaemia in type 2 DM

  15. Hypoglycaemia in type 2 DM 25% 22% UK Hypoglycaemia Study group Diabetologia 2007

  16. Morbidity of hypoglycaemia in type 2 DM • Different symptoms in elderly (eg mimic CVA) • Hypos can precipitate vascular events • T2DM pts need SAS at least as often as T1DM • Leese et al, Diabetes Care, 2003: 244 SH episodes in 160 people over 1yr in Tayside. • Emergency Rx needed for 7.1% of T1DM, 7.3% of insulin-treated T2DM and 0.8% of people on OHAs • Donnelly et al, Diabetic Medicine 2005: 267 people in Tayside with insulin-treated DM, FU for 1/12. • 45% prevalence all hypo in insulin-treated T2DM • Only 10% of T1DM with SH needed emergency services vs30% of T2DM

  17. Cognitive decline and dementia Frailty Renal dysfunction Increased mortality Institutionalisatio Old Age Hypoglycaemia T2DM Decreased symptoms Impaired counter regulation Tight glycaemic control Polypharmacy Decreased microvascular complications. No effect on macrovascular complications. Mobility limitation and decline in physical function Falls Fractures

  18. Guidelines on glycaemic targets in older pts

  19. Guidelines on glycaemic targets in older pts

  20. T2DM therapies SGLT2 inhibitors: mode of action independent of beta cells

  21. T2DM therapies • Pioglitazone: • No hypos • Wt gain, oedema, osteoporosis, ? Bladder cancer • DPP-IV: • No hypos, weight neutral • Not very potent. Reduce in renal impairment • GLP-1: • No hypos, weight loss • GI side effects, ? Pancreatitis, care in renal impairment, injections (but weekly formulation available) • SGLT2: • No hypos, weight loss, BP,  CV death (empagliflozin) • Need normal renal function. Not recommended in elderly

  22. Guidelines on glycaemic targets in older pts European Diabetes Working Party for Older People

  23. Clinical guidelines elderly T2DM

  24. Discussion

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