Slides - Canadian Diabetes Association

Report
Canadian Diabetes Association
Clinical Practice Guidelines
Diabetes in the Elderly
Chapter 37
Graydon S. Meneilly, Daniel Tessier, Aileen Knip
Diabetes in the Elderly Checklist
2013
 ASSESS for level of functional dependency (frailty)
 INDIVIDUALIZE glycemic targets based on the above
(A1C ≤8.5% for frail elderly) but if otherwise healthy,
use the same targets as younger people
 AVOID hypoglycemia in cognitive impairment
 SELECT antihyperglycemic therapy carefully
 Caution with sulfonylureas or thiazolidinediones
 Basal analogues instead of NPH or human 30/70 insulin
 Premixed insulins instead of mixing insulins separately
 GIVE regular diets instead of “diabetic diets” or
nutritional formulas in nursing homes
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Copyright © 2013 Canadian Diabetes Association
“Frailty is a widely used term associated with
aging that denotes a multidimensional
syndrome that gives rise to increased
vulnerability”
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Copyright © 2013 Canadian Diabetes Association
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Copyright © 2013 Canadian Diabetes Association
Moorhouse P, Rockwood K.
J R Coll Physicians Edinb 2012;42:333-340.
Consider A1C 7.1-8.5% if …
•
2013
Limited life expectancy
• High level of functional dependency
• Extensive coronary artery disease at high risk of
ischemic events
• Multiple co-morbidities
• History of recurrent severe hypoglycemia
• Hypoglycemia unawareness
• Longstanding diabetes for whom is it difficult to
achieve an A1C ≤7%, despite effective doses of
multiple antihyperglycemic agents, including
intensified basal-bolus insulin therapy
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Individualizing A1C Targets
2013
Consider 7.1-8.5% if:
which must be
balanced against
the risk of
hypoglycemia
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Among Frail Elderly
2013
Parameter
Target
A1C
≤8.5%
FPG or
preprandial glucose
5.0-12.0 mmol/L
(depending on level of
frailty)
AVOID HYPOGLYCEMIA
FPG= Fasting Plasma Glucose
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Copyright © 2013 Canadian Diabetes Association
Autonomic
symptoms
Older Patients have Less Perception of Hypoglycemia
14
12
10
8
6
4
2
0
**
Middle-aged
(39-64 years)
Older
(≥65 years)
Baseline
Hypo
Recovery
Neuroglycopenic
symptoms
12
*
10
8
6
4
2
0
Baseline
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Hypo
Recovery
Bremer JP et al. Diabetes Care. 2009; 32 (8):1513-17
AT DIAGNOSIS OF TYPE 2 DIABETES
Start lifestyle intervention (nutrition therapy and physical activity) +/- Metformin
L
I
F
E
S
T
Y
L
E
A1C <8.5%
If not at glycemic
target (2-3 mos)
Start / Increase
metformin
A1C 8.5%
Symptomatic hyperglycemia with
metabolic decompensation
Start metformin immediately
Consider initial combination with
another antihyperglycemic agent
Initiate
insulin +/metformin
If not at glycemic targets
Add an agent best suited to the individual:
Patient Characteristics
Degree of hyperglycemia
Risk of hypoglycemia
Overweight or obesity
Comorbidities (renal, cardiac, hepatic)
Preferences & access to treatment
Other
Agent Characteristics
BG lowering efficacy and durability
Risk of inducing hypoglycemia
Effect on weight
Contraindications & side-effects
Cost and coverage
Other
2013
See next page…
From prior page…
L
I
F
E
S
T
Y
L
E
If not at glycemic target
• Add another agent from a different class
• Add/Intensify insulin regimen
2013
Make timely adjustments to attain target A1C within 3-6 months
Add an agent best suited to the individual (agents listed in alphabetical order):
Class
Relative
A1C
Lowering
Hypoglycemia
Weight
-glucosidase inhibitor
(acarbose)

Rare
Neutral
to 
Improved postprandial control, GI
side-effects

 to
Rare
Rare
N to 

•

Yes

Incretin agents:
DPP-4 Inhibitors
GLP-1 receptor
agonists
Insulin
Insulin secretagogue:
Meglitinide
Sulfonylurea


Yes*
Yes


Thiazolidinediones

Rare

Weight loss agent
guidelines.diabetes.ca
(orlistat)

None

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Other therapeutic considerations
Cost
$$
May use detemir or glargine instead
of
$$$
NPH or human 30/70 for less hypos
GI side-effects
$$$$
• Premixed insulins and prefilled insulin
pens instead of mixing insulin to
No dose
ceiling,
flexible
regimens
$-$$$$
reduce
dosing
errors
• CAUTION
in theinelderly
*Less
hypoglycemia
context of
• Initial
doses
HALFrequires
of usual dose $$
missed
meals
but=usually
• Avoid
TID
to QIDglyburide
dosing
$
• Use gliclazide,
gliclazide
MR,
Gliclazide
and glimepiride
associated
nateglinide
withglimepiride,
less hypoglycemia
than or repaglinide
instead
glyburide
• CAUTION
in the elderly
CHF,
edema, fractures,
rare bladder
• Increased
risk of cardiovascular
fractures
cancer
(pioglitazone),
• Increased
risk of heart6-12
failure
controversy
(rosiglitazone),
weeks required for maximal effect
$$
GI side effects
$$$
If Choosing to Use Insulin …
2013
•
Clock drawing test can be used to predict who is
likely to have problems with insulin therapy
•
“Write numbers on the blank clock face and draw
hands on the clock to show 10 minutes past 11
o’clock”
Trimble LA et al. Can J Diabetes 2005;29(2):102-104.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Diabetes in Nursing Homes
2013
•
Under nutrition is a problem in people with diabetes
living in nursing homes
•
“Regular diets” may be used in nursing homes
instead of “diabetic diets” or “diabetic nutritional
formulas”
Mooradian AD et al. J Am Geriatr Soc 1988;36:391-396
Coulston AM et al. Am J Clin Nutr 1990;51:67-71.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Recommendation 1
1. Healthy, elderly people with diabetes should be
treated to achieve the same glycemic, blood
pressure, and lipid targets as younger people with
diabetes [Grade D, Consensus].
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Copyright © 2013 Canadian Diabetes Association
Recommendation 2
2013
2. In the frail elderly, while avoiding symptomatic
hyperglycemia, glycemic targets should be an A1C
of ≤8.5% and FPG or pre-prandial PG of
5.0-12.0 mmol/L, depending on the level of frailty.
Avoidance of hypoglycemia should take priority
over attainment of glycemic targets because the
risks of hypoglycemia are magnified in this patient
population [Grade D, Consensus].
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Recommendations 3 and 4
3. In elderly people with cognitive impairment,
strategies should be employed to strictly avoid
hypoglycemia, which include the choice of
antihyperglycemic therapy and less stringent A1C
target [Grade D, Consensus].
4. Elderly people with type 2 diabetes should perform
aerobic exercise and/or resistance training, if not
contraindicated, to improve glycemic control [Grade B,
Level 2].
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Copyright © 2013 Canadian Diabetes Association
Recommendation 5
5. In elderly people with T2DM, sulfonylureas should
be used with caution because the risk of
hypoglycemia increases exponentially with age
[Grade D, Level 4].
–
–
–
In general, initial doses of sulfonylureas in the elderly
should be half of those used for younger people, and doses
should be increased more slowly [Grade D, Consensus].
Gliclazide and gliclazide MR [Grade B, Level 2] and
glimepiride [Grade C, Level 3] should be used instead of
glyburide, as they are associated with a reduced frequency
of hypoglycemic events.
Meglitinides may be used instead of glyburide to reduce
the risk of hypoglycemia [Grade C Level 2 for repaglinide; Grade C,
Level 3 for nateglinide], particularly in patients with irregular
eating habits [Grade D, Consensus].
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Copyright © 2013 Canadian Diabetes Association
Recommendation 6
6. In elderly people, thiazolidinediones should be used
with caution due to the increased risk of fractures
and heart failure [Grade D, Consensus].
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Recommendations 7 and 8
7. Detemir and glargine may be used instead of NPH
or human 30/70 insulin to lower the frequency of
2013
hypoglycemic events [Grade B, Level 2].
8. In elderly people, if insulin mixture is required,
premixed insulins and prefilled insulin pens
2013
should be used instead of mixing insulins to
reduce dosing errors, and to potentially improve
glycemic control [Grade B, Level 2].
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Recommendations 9 and 10
2013
9. The clock drawing test may be used to predict
which elderly subjects will have difficulty learning to
inject insulin [Grade D, Level 4].
10. In elderly nursing home residents, regular diets may
be used instead of “diabetic diets” or nutritional
formulas [Grade D, Level 4].
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
CDA Clinical Practice Guidelines
www.guidelines.diabetes.ca – for professionals
1-800-BANTING (226-8464)
www.diabetes.ca – for patients

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