Study highlights need to enhance glycemic management for older adults

What are the challenges providing older adults with optimal type 2 diabetes care?

A cross-sectional analysis published in the Journal of the American Geriatrics Society found that one-quarter of older adults with type 2 diabetes were tightly controlled and receiving glucose-lowering medications with high risk for hypoglycemia.

Investigators examined 30,969 patients aged 75 and older who participated in The Diabetes Collaborative Registry between 2014 and 2016, then categorized them based on A1C and types of antihyperglycemic medications. Data suggested that the availability of safer treatment options and updated guideline statements had not improved antidiabetic management for older adults. Furthermore, examination of practice patterns found treatment gaps with concerning risk for hypoglycemia in older Americans, which represent opportunities for improvement in their glycemic management.

“The incidence of serious hypoglycemia in older adults with diabetes increases with age,” said Demetra Antimisiaris, PharmD, BCGP, FASCP, associate professor at the University of Louisville (UL) College of Medicine and lead of the UL Frazier Polypharmacy and Medication Management Program. “Older adults with diabetes are more susceptible to hypoglycemia and hypoglycemic injury than younger patients for reasons related to social determinants of health, the physiology of aging, the long-term effects of hyperglycemia, and because hypoglycemia is underrecognized in older adults by clinicians and other stake holders.”

One challenge to providing older adults with gold-standard type 2 diabetes care is variability in guideline recommendations. The American Geriatrics Society recommends A1C levels generally from 7.5% to 8%. Meanwhile, American Diabetes Association (ADA) guidelines have suggested targets below 7% for healthy patients and 7.5% to 8% otherwise. Guidelines by the American Association of Clinical Endocrinologists recommended A1C goals below 6.5% for new-onset disease or healthy patients and above 7% in patients presenting with multiple comorbidities or labile glycemia.

“There are likely many reasons why some older adults are too intensively managed,” said Joshua Neumiller, PharmD, CDE, FAADE, FASCP, associate professor at Washington State University College of Pharmacy and Pharmaceutical Sciences and chair of ADA’s Professional Practice Committee. “One potential contributor is that current guidelines provide more detail on how to intensify treatment and less on how to deintensify therapy in older adults; thus clinicians have less guidance on de-escalation of therapy.”

While newer agents carry less risk for hypoglycemia, they are more expensive when compared with older agents that have a higher risk for hypoglycemia, making access an issue. Another potential contributor, Neumiller explained, is the use of A1C thresholds as clinical performance measures without considering appropriate A1C goals in individual patients.

“Keep in mind that most of the [type 2 diabetes] guidelines were derived from clinical studies excluding the older, multimorbid, and frail adults,” said Antimisiaris. “The care of older adults with diabetes requires individualized attention and education focusing on drug administration, dosing, monitoring, and care support.”

For the full article, please visit www.pharmacytoday.org for the October 2018 issue of Pharmacy Today.