10 practical tips for treating older patients with diabetes

Aim for a BP target of 140/90mmHg, the US Endocrine Society says in their new guidance

Treatment regimes for patients over 65 with diabetes should be tailored to each patient to reduce the risk of hypoglycaemia, according to new US recommendations developed by the Endocrine Society.

older patient with diabetes

The updated clinical practice guideline, containing 35 recommendations, was released at the Society’s conference in New Orleans, US, on Saturday and is due to be published in the Journal of Clinical Endocrinology & Metabolism in May.

Other recommendations for patients aged 65 or older include:

  1. Use fasting glucose and/or HbA1c screenings to diagnose diabetes or pre-diabetes. If patients meet the criteria for prediabetes, a two-hour glucose post-oral glucose tolerance test is recommended. Repeat screening every two years if the initial screening test is normal.
     
  2. Treatment regimes for patients with diabetes should be individually designed to reduce the risk of hypoglycaemia. In patients with cognitive impairment, glycaemic targets should be more lenient to improve compliance and prevent treatment-related complications.
     
  3. Lifestyle programs are recommended for patients with pre-diabetes. Metformin should be avoided.
     
  4. Lifestyle programs are also first-line treatment for hyperglycaemia for older, ambulatory patients with diabetes. If patients can’t reach glycaemic targets through lifestyle changes, limit consumption of simple sugars but avoid restrictive diets.
     
  5. Metformin is the first-line oral agent for glycaemic control, in addition to lifestyle changes, except in patients with significantly impaired kidney function (glomerular filtration rate less than 30mL/min/1.73m2) or gastrointestinal intolerance.
     
  6. Add insulin and/ or other oral agents if glycaemic targets are not achieved with metformin and a lifestyle program. Avoid sulfonylureas and use insulin sparingly.
     
  7. The blood pressure target is 140/90mmHg. If lower targets are set, careful monitoring is required to avoid orthostatic hypotension.
     
  8. Patients need an annual lipid profile and statin therapy to meet the recommended levels for reducing the risk of cardiovascular disease and all-cause mortality. The target can be more lenient for patients over 80 or with a short life expectancy. Fish oil and/or fenofibrate are recommended to reduce the risk of pancreatitis in patients with fasting triglycerides above 500mg/dL.
     
  9. Use low-dose aspirin (75-162mg/day) for patients with a history of cardiovascular disease after assessing for bleeding risk.
     
  10. Clear targets of 5.55-7.77mmol/L fasting and 7.77-10mmol/L post-prandial — while avoiding hypoglycaemia — are recommended for patients in aged care facilities

More information: Journal of Clinical Endocrinology & Metabolism 2019