COMMENTARY

Managing Diabetes in Older Adults: A Review of the New Endocrine Society Guidelines

Anne L. Peters, MD

Disclosures

March 27, 2019

Editorial Collaboration

Medscape &

This transcript has been edited for clarity.

Today I'm going to talk about the new Endocrine Society clinical practice guideline[1] on the treatment of diabetes in older adults. This is a very thorough, very complete guideline, although they are always limited by space and time. So, even after 2 years, there are a number of questions that remain to be resolved, which will happen over time as people get used to this guideline.

What's interesting and very important is that the guideline walks through various phases. First, it discusses the diagnosis of prediabetes and type 2 diabetes, then it moves on to looking at glycemic targets. There is a lot of discussion about individualization of care and working with primary care, because primary care providers are going to contribute a lot to the care of these patients.

They discuss looking at patients' frailty, their ability to function, and their ability to do activities of daily living. They then go on to discuss the various treatments for diabetes, followed by guidelines on treatment of both hypertension and hyperlipidemia.

A1c Still Useful?

The first part of the guideline is about diagnosing prediabetes and diabetes. To me, this is the most controversial and perhaps the least practical part of the guideline. What I mean by that is that they suggest an oral glucose tolerance test as a second test for diagnosing diabetes or prediabetes, from which the 2-hour value is used to diagnose prediabetes or diabetes.

I am—as probably most of you are—most used to using a fasting glucose level or a hemoglobin A1c for diagnosing diabetes or prediabetes, but they made a very cohesive argument about how an A1c sort of falls away in terms of being useful as a population ages, particularly in individuals older than 75 years of age, those with chronic renal disease, and those with various states of anemia. So the reason they suggest that 2-hour value is because they feel that it will be the most accurate way to diagnose diabetes and prediabetes in an older population.

From my perspective, I will still look at both the fasting glucose value and hemoglobin A1c but then do a confirmatory test. And say, for instance, that a fasting glucose is 115 mg/dL and you wish to do another confirmatory test. It could be a 2-hour glucose tolerance test, as suggested in the guidelines. But practically speaking, I'd probably still do an A1c, because it would be involved in guiding my treatment as well as helping me diagnose the patient. If the hemoglobin A1c is elevated, it's likely indicative of the patient having diabetes.

But again, they really clarify that if you want the most accurate way to diagnose prediabetes and diabetes in this population, you need to consider doing the 2-hour glucose tolerance test.

Staying on Target

They then go on to look at targets. And it's interesting, because this is the first time I've really seen a lower limit given for an A1c target. Instead of saying that the A1c should be < 7, < 8, or < 8.5, they look at patients to see whether they're on a drug that can cause hypoglycemia. If a patient is on a drug that can cause hypoglycemia, such as insulin or a sulfonylurea agent, they have a lower limit to that range, below which they don't want patients to go in order to avoid hypoglycemia.

One part of the table for targets looks at whether the patient is on drugs that cause hypoglycemia, with a different range for those who are on agents that can cause hypoglycemia. And then they divide patients into three functional categories, which are not based on an absolute age but in terms of how well the patient can achieve those targets: whether a patient has comorbidities, whether they have elements of dementia, and whether they're able to take care of themselves and perform the diabetes self-care tasks. They did an excellent job of making a framework for defining targets for patients as we proceed forward in treatment.

Managing Glycemia

In regard to treatment, there are nice tables that list the pros and cons of various treatments. They also stress the importance of limiting hypoglycemia and, if at all possible, avoiding agents that can cause hypoglycemia.

Throughout this, they discuss working with the primary care team, working with patients in terms of their preferences and tolerances, and really moving forward in a way that involves a team.

A particularly important part of the team is a registered dietitian, someone who can work with patients as they age to help them eat in a healthy way. There's a lot of discussion about the sarcopenia that can occur. What happens is that patients lose their appetite, eat less, and start to weigh less. A lot of that is important as patients age, and we need to keep them healthy, have them eat enough protein, and eat a diet that keeps them strong but is as consistent as possible, particularly if they're on drugs that can cause hypoglycemia.

Lipids and Hypertension

After discussing the management of glycemia, they look at the management of both lipids and hypertension. The lipid targets are somewhat complicated because there aren't much data for an older age group, but they stick fairly closely to the standard targets—looking at risk, looking at an LDL < 100 or < 70 mg/dL in those higher-risk patients. They're fairly standard lipid-lowering guidelines.

Again, they discuss individualizing treatment and looking at what a patient might benefit from. As people get older, polypharmacy becomes quite an issue, so we need to make judicious choices with our patients about treatment.

Finally, for the management of hypertension, they discuss a target blood pressure of < 140/90 mm Hg for most patients. In patients who have other conditions, like chronic kidney disease, where you need a lower blood pressure, they discuss a target of < 130/80 mm Hg. They discuss concerns about orthostatic hypotension and autonomic neuropathy in people with very longstanding diabetes, and advise considering these as targets are titrated and reached in individual patients.

These guidelines are very expansive, very useful, and very well evidence-based. The one thing they don't discuss, but do mention, is how to de-escalate therapy. It's important to stop medications as indicated to help patients stay healthy and maintain use of medications that are effective. Overall, this is a great guideline, and I encourage you to read it. Thank you.

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