New Endocrine Society Guidelines Address Diabetes in Older Adults

Miriam E. Tucker

March 23, 2019

NEW ORLEANS — New guidelines from the Endocrine Society address the numerous complex issues involved in managing the growing population of older adults with diabetes.

The document, Treatment of Diabetes in Older Adults: An Endocrine Society Clinical Practice Guideline, was presented March 23 here at ENDO 2019: The Endocrine Society Annual Meeting and was simultaneously published in the Journal of Clinical Endocrinology and Metabolism along with other online resources.

The guidelines are cosponsored by the European Society of Endocrinology, the Gerontological Society of America, and the Obesity Society.

"For many decades and many years, we have not really paid a lot of attention to the older individual with diabetes because they were considered to have a limited lifespan. But we now know that 65 to 70 year olds live until 85 to 90 years, and so preventing the long-term complications is very important, much as the short-term issues they suffer from," said committee chair Derek LeRoith, MD, PhD, of the Icahn School of Medicine at Mount Sinai, New York City, during a press briefing.    

The document specifically pertains to adults with diabetes aged 65 years and older. It covers screening, prevention, and management of glycemia, blood pressure, and lipids, as well as comorbidities, complications, and special situations such as diabetes care in the hospital and long-term care facilities, and management of type 1 diabetes in older adults.

"We believe there should be regular screening. If you screen for prediabetes and diabetes in the older population, it can allow you to intervene," LeRoith said.

And, importantly, because of the heterogeneity of health status in older people with diabetes, the document emphasizes shared decision-making and provides a framework to assist healthcare providers to individualize treatment goals. "We believe that all the decisions in terms of management of these patients should be a team approach," he stressed.

Avoidance of hypoglycemia is a key issue, coauthor Mark E. Molitch, MD, of the Northwestern University Feinberg School of Medicine, Chicago, Illinois, told journalists during the briefing.

"A 70 year old who has hypoglycemia and falls on the floor can fracture a hip, so we have to be very careful about avoiding hypoglycemia. Similarly, for blood pressure we don't want to be too aggressive because that can lead to falls. All of these things play a role in how to adjust medications for these patients."

Other specific aging-related comorbidities and issues addressed in the guidelines include sarcopenia, frailty, cognitive dysfunction, diminished medication adherence, and loss of independence in daily living activities.

In addition, "Both renal disease and cardiac disease are very important, and we discuss that in these guidelines," LeRoith said.

Comparison to Other Guidelines

The new guidelines cover much the same ground as the 2012 American Diabetes Association/American Geriatrics Society (ADA/AGS) guidelines, noted Medha Munshi, MD, director of the Joslin Geriatric Diabetes Programs at Beth Israel Deaconess Medical Center, Boston, in an interview with Medscape Medical News.

Munshi was a coauthor on the ADA/AGS guidelines, which have since been revised in the 2019 ADA Standards of Medical Care in Diabetes.

"I think the guidelines add to each other. Most older adults with diabetes will be better taken care of if these basic concepts are understood."

Munshi specifically praised the new Endocrine Society document's emphasis on hypertension and lipid management in addition to glycemia and its involvement of patients as consultants. 

She also noted that the two sets of guidelines similarly classify older adult patients into categories of good health (ie, no or few comorbidities, and no or few functional impairments), intermediate health (three or more comorbidities, mild cognitive impairment, and/or two or more functional impairments), and poor health (end-stage medical condition[s], moderate-severe dementia, two or more functional limitations, and/or residence in a long-term nursing facility). 

But Munshi praised the Endocrine Society for adding an additional category to that framework: use of drugs that may cause hypoglycemia, such as insulin, sulfonylureas, or glinides.

However, within that framework she questioned the evidence base for some of the recommended HbA1c target ranges, one such example is between ≥ 7.0% and < 7.5% for patients in good health using hypoglycemia-prone medications.

Some patients within that category may need a higher target, she noted.

"There's no real data for that recommendation. It's just expert opinion. Instead of liberalizing the higher level, they're putting it in the tighter range."

She also faulted the document for not providing specific instructions for simplifying regimens, as is recommended for patients with limited life expectancy, cognitive impairment, and/or multiple comorbidities.

Such guidance, first included in the 2016 ADA guidelines on diabetes care in skilled nursing and long-term care facilities, was added to the ADA's recommendations in the current Standards of Care.

"Simplification is a good philosophy, but hard for practitioners to put into practice," Munshi commented.

She was the lead author of those 2016 long-term care guidelines, emphasizing that it was important to provide different guidance for the different settings.

"Hospitals and long-term care facilities are very different environments, with very different management goals," she told Medscape Medical News. "In the ADA statement I explained why they don't belong together, but the Endocrine Society has again lumped them together."

Does Type 1 Diabetes in Older Adults Merit Separate Guidelines?  

And, although the Endocrine Society document includes a paragraph on management of type 1 diabetes in older adults, Munshi said that the growing population really merits separate guidelines.

"With type 1 diabetes, much is expert opinion as there is not a lot of data," she said, adding that long-term care is a main concern in this population.

"The lack of understanding about how different insulins work and how to manage diabetes generally in the type 2 population is difficult enough, and then you put in a type 1 patient...We need to write something about type 1 diabetes in long-term care."

But generally, Munshi said the Endocrine Society's new guidelines will enhance care for older adults and that the differences between the documents overall are minor.

"The main concepts are the same...As long as the guidelines reach wider audiences, they will give people a better understanding of the complexities of managing older adults with diabetes."

LeRoith is a consultant for AstraZeneca and MannKind, and serves on advisory boards for MSD. Molitch is a consultant for and/or serves on data safety monitoring boards for Merck, Pfizer, Janssen, Chiasma, and Novartis. Munshi is a consultant for Sanofi and Lilly.

ENDO 2019. Presented March 23, 2019.

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