Glycemic Control In Older Patients Research Articles

Risk Factors and Adverse Outcomes of Hypoglycemia in Older Patients with Type 2 Diabetes Mellitus

Currently, the world is experiencing a steady increase in the number of patients with type 2 diabetes mellitus (T2DM); this disease is recognized as a global medical and social problem of the 21st century. There is also a trend towards increasing life expectancy and, as a result, an aging population. Accordingly, the number of older patients with T2DM is increasing. Hypoglycemia, a serious complication of T2DM, is quite common among this category of patients. Hypoglycemia leads to worsening glycemic control, cognitive deficits, and an increased risk of adverse cardiovascular outcomes in older patients. This review examines the risk factors for hypoglycemic conditions that must be taken into account when prescribing glucose-lowering therapy to older patients and their prognostic significance in assessing the risk of hypoglycemia. The possible negative consequences of hypoglycemia are described and the importance of individual goals for glycemic control in older patients is emphasized.

Switching from Neutral Protamine Hagedorn (NPH) Insulin to Insulin Glargine 300U/mL in Older and Younger Patients with Type 2 Diabetes: A Post Hoc Analysis of a Multicenter, Prospective, Observational Study.

IntroductionOlder age and longer disease duration are key risk factors for hypoglycemia in patients with type 2 diabetes (T2D) who receive insulin. Previous studies have shown that insulin glargine 300 U/mL (Gla-300) improves glycemic control and reduces the risk of hypoglycemia, but whether this effect is observed in older patients switching from neutral protamine Hagedorn (NPH) insulin is unclear.MethodsIn this multicenter, observational study involving patients with T2D aged ≥ 18 years with glycated hemoglobin (HbA1c) ≥ 8%, we compared the safety and effectiveness of switching from NPH insulin to Gla-300 in subgroups of patients differing by age (< 65 vs. ≥ 65 years) and duration of diabetes (≤ 13 vs. > 13 years).ResultsA total of 469 participants were included in the study. From baseline to 6 months after switching to Gla-300, mean HbA1c decreased from 9.23% to 8.13% (p < 0.001) among patients aged ≤ 65 years (224 patients), and from 9.15% to 8.20% (p < 0.001) among those aged > 65 years (245 patients). The proportion of patients with ≥ 1 episodes of hypoglycemia decreased from 19.1% to 13.6% (p = 0.11) among those aged ≤ 65 years, and from 27.6% to 13.0% (p < 0.001) among those aged > 65 years; the reduction was significantly greater in those aged > 65 years (p = 0.001). The reduction in HbA1c was greater in those with a disease duration ≤ 13 years (p = 0.007), but the reduction in hypoglycemia was greater in those with a disease duration > 13 years (p < 0.0003).ConclusionThe switch from NPH insulin to Gla-300 improved glycemic control in older patients with T2D and in those with a longer disease duration. Older patients with T2D and those with a longer disease duration benefited even more from the switch to Gla-300 than younger patients and those with a shorter disease duration, with significantly greater reductions in the risk of hypoglycemia. Video Infographic Supplementary InformationThe online version contains supplementary material available at 10.1007/s13300-021-01199-4.

Glycemic control and use of glucose-lowering medications in hospital-admitted type 2 diabetes patients over 80 years

Treatment guidelines for type 2 diabetes (T2D) recommend avoidance of hypoglycemia and less stringent glycemic control in older patients. We examined the relation of glycemic control to glucose-lowering medications use in a cohort of patients aged>80 years with a diagnosis of T2D and a hospital admission in the Capital Region of Denmark in 2012–2016. We extracted data on medication use, diagnoses, and biochemistry from the hospitals’ records. We identified 5,172 T2D patients with high degree of co-morbidity and where 17% had an HbA1c in the range recommended for frail, comorbid, older patients with type 2 diabetes (58–75 mmol/mol (7.5–9%)). Half of the patients (n = 2,575) had an HbA1c <48 mmol/mol (<6.5%), and a majority of these (36% of all patients) did not meet the diagnostic criteria for T2D. Of patients treated with one or more glucose-lowering medications (n = 1,758), 20% had HbA1c-values <42 mmol/mol (<6%), and 1% had critically low Hba1c values <30 mmol/mol (<4.9%), In conclusion, among these hospitalized T2D patients, few had an HbA1c within the generally recommended glycemic targets. One third of patients did not meet the diagnostic criteria for T2D, and of the patients who were treated with glucose-lowering medications, one-fifth had HbA1c-values suggesting overtreatment.

A retrospective cross-sectional study of type 2 diabetes overtreatment in patients admitted to the geriatric ward

BackgroundGlycemic control targets in older patients should be individualized according to functional status and comorbidities. The aim of the study was to identify high-risk patients who had evidence of tight glycemic control and thus at risk of serious hypoglycemia.MethodsRetrospective cross-sectional study of type 2 diabetes patients admitted to the geriatric ward receiving diabetes medications. Patients’ hospital records were analyzed. The high risk of hypoglycemia group constituted patients who were aged 80+ years, diagnosed with dementia, with end- stage renal disease, or with a history of macrovascular complications. The primary outcome measure was hemoglobin A1C (HbA1C) ≤ 7.0% [53 mmol/mol].ResultsTwo hundred thirteen patients were included (77.5% women; 49.3% 80+ year-old). 65.3% received sulfonylurea, 39,4%- metformin, 32.9%- insulin, and 4.2%- acarbose (in 61.5% as monotherapy, and in 38.5% combination therapy). We identified 130 patients (60%) as the denominator for the primary outcome measure; 73.1% had a HbA1C value ≤7.0% [53.3 mmol/mol], but 55.4% ≤6,5% [48.8 mmol/mol], and 40.8% ≤6.0% [42 mmol/mol].ConclusionsThe results show a very high rate of tight glycemic control in older patients admitted to the geriatric ward, for whom higher HbA1C targets are recommended. This indicates the high probability of diabetes overtreatment in this group, associated with a high risk of recurrent hypoglycemia. This is all the more likely because most of them received medications known to cause hypoglycemia. This points to the need of paying more attention to specific difficulties in diabetes treatment in older people, especially those suffering from various geriatric syndromes and diseases worsening their prognosis.

Effects of low-intensity resistance training on muscular function and glycemic control in older adults with type2 diabetes.

Aims/IntroductionThe present study aimed to investigate the effects of low‐intensity resistance training with slow movement and tonic force generation (LST) on muscular function and glucose metabolism in older patients with type 2 diabetes.Materials and MethodsA total of 10 patients with type 2 diabetes (age 68.2 ± 9.7 years) engaged in LST training twice a week for 16 weeks. Before the long‐term intervention, they were subjected to the measurement of acute changes in blood factors relating to glycemic control as a result of a bout of LST. Body composition, muscular size and strength, and glycated hemoglobin were measured before and after the intervention.ResultsThe magnitudes of the acute changes in the blood factors were all small and were not considered harmful for glucose metabolism. The 16‐week LST training caused significant increases in thigh muscle thickness and strength, and decreases in body fat mass and glycated hemoglobin. The change in glycated hemoglobin showed a significant negative correlation with the change in the isokinetic knee extension peak torque measured at a high angular velocity (180°/s).ConclusionsThe LST training was shown to be effective for gaining muscular size and strength, and improving glycemic control in older patients with type 2 diabetes. The mechanisms underlying this effect might involve the improvement of contractile function in fast glycolytic fibers.

Physical Activity and Diabetes.

Physical Activity and Diabetes.

Treatment Patterns and Glycemic Control in Older Adults with Type 2 Diabetes Mellitus Receiving Only Oral Antidiabetes Drugs in China.

Only a few studies have reported the use of oral antidiabetes drugs (OADs) for treating older adults with type 2 diabetes mellitus (T2DM) in China. This study assessed the status of OAD therapy and relevant factors associated with OAD treatment patterns and glycemic control among older patients. We conducted a noninterventional, observational, cross-sectional, multicenter study, which was initiated by the Chinese Diabetes Society, in which 9,872 outpatients with T2DM were recruited who received OADs only. Current antidiabetes treatment regimens and related clinical data were collected from patients' self-reporting and medical records. Participants were divided into two groups: ≥65 years and <65 years. All data were tabulated, and statistical analyses were performed using SPSS version 16 software (SPSS Inc., Chicago, IL). Insulin secretagogues (52.6%): sulfonylureas (SU) (26.6%) and glinides (26.0%) were commonly used as monotherapy in those ≥65 years. The most popular OAD pattern was dual combination therapy (46.8%), with SU plus glucosidase inhibitors (25.1%) being most common in older participants. Age, diabetes duration, body mass index, achieving the glycemic control targets, and hypoglycemia were influencing factors to those ≥65 years in diverse treatment pattern models (P < 0.05). Older patients receiving OADs with triple or more combination treatment and complications were more likely to have substandard glycemic control (hemoglobin A1c level ≥7%). The pattern of OADs alone in older adults with T2DM was significantly different from those <65 years in China. A comprehensive OAD treatment pattern or insulin combination may be necessary for better glycemic control in older patients with multiple combinations of OADs or complications.

Lixisenatide treatment for older patients with type 2 diabetes mellitus uncontrolled on oral antidiabetics: meta-analysis of five randomized controlled trials.

Evaluate the efficacy and safety of lixisenatide, a once-daily prandial glucagon-like peptide-1 receptor agonist, in older patients with type 2 diabetes mellitus (T2DM) insufficiently controlled on oral antidiabetics (OADs). A meta-analysis was conducted on data from older patients (≥65 years) from five of the GetGoal trials, in which patients with T2DM were treated with lixisenatide 20 µg once daily or placebo, as an add-on to OADs. The primary endpoint in all trials was change from baseline at week 24 in glycated hemoglobin (HbA1c). Other endpoints included changes in post-prandial plasma glucose (PPG), fasting plasma glucose (FPG) and weight. Composite and safety endpoints were also analyzed. A total of 501 patients aged ≥65 years were included in this meta-analysis: 304 received lixisenatide plus OADs and 197 received placebo as add-on to OADs. Lixisenatide as an add-on to OADs significantly reduced HbA1c, PPG, FPG and weight, with placebo-corrected treatment effects at week 24 of -0.54% (p<0.0001), -126 mg/dL (p<0.0001), -13 mg/dL (p=0.0005) and -0.90 kg (p=0.0021), respectively. Patients receiving lixisenatide plus OADs were significantly more likely to achieve composite (HbA1c levels<7%, HbA1c levels<7% and no symptomatic hypoglycemia, and HbA1c levels<7%, no weight gain and no symptomatic hypoglycemia) and safety endpoints than those receiving placebo plus OADs. Symptomatic hypoglycemia was experienced by 8.55% and 3.55% of patients in the lixisenatide plus OADs and placebo plus OADs groups, respectively (p=0.0276), although no serious hypoglycemic episodes were reported. Lixisenatide plus OADs improved glycemic control in older patients inadequately controlled on OADs compared with placebo plus OADs. Lixisenatide is well tailored to the pathophysiology of T2DM in older patients.

Durability of glycemic control with insulin lispro mix 75/25 versus insulin glargine for older patients with type 2 diabetes.

Background and AimsFew studies have evaluated long-term durability of glycemic control in older patients. The aim of this study was to compare durability of glycemic control of twice-daily insulin lispro mix 75/25 (LM75/25; 75 % insulin lispro protamine suspension, 25 % insulin lispro) and once-daily insulin glargine (GL) added to oral antihyperglycemic medications in older patients (≥65 years of age).MethodsPatients were participants in the maintenance phase of the DURABLE trial. During the initiation phase, patients with type 2 diabetes were randomized to LM75/25 or GL. After 6 months, patients with hemoglobin A1c (HbA1c) ≤7.0 % advanced to the 24-month maintenance phase. The primary objective was between-group comparison of duration of maintaining the HbA1c goal in older patients (≥65 years of age). A similar analysis was conducted for older patients achieving HbA1c ≤6.5 % in the initiation phase.ResultsMedian time of maintaining HbA1c goal was longer in LM75/25 versus GL (19.6 versus 15.4 months, p = 0.007) and more LM75/25 patients maintained goal versus GL (49.2 versus 30.4 %; p = 0.003). HbA1c reduction from baseline was greater in LM75/25 versus GL (−1.56 ± 0.10 versus −1.24 ± 0.11 %; p = 0.003). Post-meal glucose was significantly lower in LM75/25 versus GL (158.86 ± 3.42 versus 171.67 ± 4.51 mg/dL; p = 0.017). No differences were observed in overall and severe hypoglycemia. LM75/25 patients had higher daily insulin doses (0.41 ± 0.02 versus 0.32 ± 0.02 units/kg/day; p < 0.001) and more weight gain (5.47 ± 0.49 versus 3.10 ± 0.53 kg; p = 0.001). Similar results were generally obtained in older patients with HbA1c ≤6.5 %.ConclusionsIn our evaluation of older patients from a larger trial, LM75/25 appeared to provide longer durability of glycemic control, as well as a greater number of patients maintaining HbA1c goal versus GL.

Efficacy and Safety of Insulin Glargine Compared to Other Interventions in Younger and Older Adults: A Pooled Analysis of Nine Open-Label, Randomized Controlled Trials in Patients with Type 2 Diabetes

Elderly patients with type 2 diabetes mellitus (T2DM) present therapeutic challenges related to co-morbidities, treatment adherence, and safety. This study examines the efficacy and safety of insulin glargine compared to other glucose-lowering interventions in younger and older adults. In this pooled analysis of 24-week data from nine prospective open-label, multicenter, phase 3/4, two-arm, parallel-group, randomized controlled trials, patients with T2DM aged 18-80 years received insulin glargine (used as a basal insulin regimen) or comparators (including rosiglitazone, pioglitazone, insulin lispro, insulin lispro 75/25, NPH insulin, NPH insulin 30/70, and lifestyle/dietary measures). Endpoints included change from baseline to week 24 in: glycated hemoglobin; fasting plasma glucose; body weight; body mass index; insulin dose; incidence of nocturnal, daytime, or any hypoglycemia. Results were stratified by age (<65, ≥65, 65-74, and ≥75 years) and treatment (insulin glargine or comparator). A total of 2,938 patients were included (2,263 aged <65 years, 675 aged ≥65 years). Similar levels of glycemic control were achieved in both younger (<65 years) and older (≥65 years) patients with T2DM. Insulin glargine was associated with better glycemic control and a reduced incidence of daytime and any hypoglycemia versus comparator interventions in both younger and older T2DM patients. This analysis suggests that insulin glargine may represent a safe option to improve glycemic control in older patients with T2DM.

Does comorbidity affect the benefit of intensive glycemic control in older patients with type 2 diabetes mellitus?

Does comorbidity affect the benefit of intensive glycemic control in older patients with type 2 diabetes mellitus?

Comparative efficacy of preprandial or postprandial humalog ® mix75/25™ versus glyburide in patients 60 to 80 years of age with type 2 diabetes mellitus

Background: Humalog ® Mix75/25™ (Mix75/25) is a novel premixed insulin containing 75% neutral protamine lispro (an intermediate-acting insulin) and 25% insulin lispro. Objective: The purpose of this study was to compare glycemic control and hypoglycemia rates with Mix75/25 versus glyburide, and with preprandial versus postprandial Mix75/25, in patients aged 60 to 80 years with type 2 diabetes mellitus and persistent hyperglycemia on sulfonylurea therapy. Methods: In this open-label, 16-week, parallel-group study, patients were randomized to 1 of 2 treatments: glyburide 15 mg/d (or up to the maximum daily dose) or Mix75/25. The Mix75/25 group was randomly subdivided into preprandial (immediately before breakfast and dinner) and postprandial (within 15 minutes after the start of breakfast and dinner) injection subgroups. The primary outcomes were glycemic control and rate of hypoglycemia. Results: A total of 143 patients were randomized; 127 completed the study. The change in glycosylated hemoglobin (HbA 1c) from baseline to end point was significantly greater with Mix75/25 than with glyburide (mean ± SEM, −1.14% ± 0.18% vs −0.36% ± 0.15%, P = 0.001). HbA 1c changes with preprandial and postprandial Mix75/25 were not significantly different (−1.20% ± 0.26% vs −1.08% ± 0.26%, P = 0.748). Fasting blood glucose (BG), 2-hour postprandial BG, and mean daily BG reductions were greater with Mix75/25 than with glyburide ( P < 0.001); preprandial and postprandial Mix75/25 administration did not differ significantly with respect to any of these BG variables. The hypoglycemia rate increased with Mix75/25 by 0.17 ± 0.02 episodes per patient per 30 days, but there was no change with glyburide ( P = 0.077). Body weight increased by 1.02 ± 0.35 kg with Mix75/25 and decreased by 0.85 ± 0.18 kg with glyburide ( P < 0.001). Conclusions: Compared with glyburide, Mix75/25 significantly improved glycemic control in older patients with type 2 diabetes mellitus, could be administered after meals without compromising glycemic control, and was well tolerated.