Is treatment warranted for an 85-year-old male with a history of prediabetes (impaired glucose regulation), erectile dysfunction (ED), hypertension (HTN), benign prostatic hyperplasia (BPH), and a previous cerebral infarction (stroke) with gait instability, who remains in the prediabetic range?

From the Guidelines

Treatment for prediabetes in an 85-year-old patient with multiple comorbidities is generally warranted but should be approached conservatively, prioritizing lifestyle modifications and considering metformin at a low dose if kidney function is adequate, as recommended by the most recent guidelines 1. The patient's complex medical history, including erectile dysfunction, hypertension, benign prostatic hyperplasia, cerebral infarction, and gait instability, necessitates a cautious approach to treatment.

• Lifestyle modifications should be the primary focus, including:
  • A Mediterranean or DASH diet
  • Moderate physical activity as tolerated (such as walking 15-30 minutes daily or chair exercises)
  • Maintaining a healthy weight
• Regular blood glucose monitoring is recommended, typically once daily or as advised by the healthcare provider.
• Metformin at a low dose (500 mg daily with meals) could be considered if kidney function is adequate (eGFR >30 mL/min), but should be started cautiously with close monitoring for side effects, as noted in the 2025 guidelines 1. The treatment approach for elderly patients with prediabetes should prioritize quality of life and avoiding hypoglycemia, which can increase fall risk and cognitive impairment, as highlighted in the 2019 ESC guidelines 1.
• Goals should be individualized, typically aiming for an A1C of 7.5-8.0% rather than stricter targets used for younger patients.
• Regular follow-up every 3-6 months is important to assess treatment effectiveness and adjust the plan as needed based on the patient's overall health status and functional capacity. It is essential to weigh the risk versus benefit of each medication in support of person-centered goals, considering cost and burden of administration, as emphasized in the 2025 guidelines 1. Additionally, pharmacologic interventions must be long-term because of the waning of effect after stopping the medication, and the potential for vitamin B12 deficiency with long-term metformin use should be monitored annually 1.

From the FDA Drug Label

If you are over 80 years old you should not take metformin hydrochloride tablets unless your kidneys have been checked and they are normal. The patient is 85 years old and has a history of prediabetes, but the FDA label does not directly address the treatment of prediabetes with metformin in patients over 80 years old.

• Key consideration: The patient's kidney function should be checked before initiating metformin therapy, as stated in the label.
• Clinical decision: Treatment with metformin may not be warranted at this age, unless the patient's kidney function is normal, and other factors are considered by the healthcare provider 2.

From the Research

Patient Profile

• The patient is 85 years old with a history of prediabetes, erectile dysfunction (ED), hypertension (HTN), benign prostatic hyperplasia (BPH), cerebral infarction, and gait instability.
• Recent laboratory results indicate that the patient is still in the prediabetic range.

Treatment Considerations

• According to 3, a fixed-dose combination of pioglitazone and metformin can improve glycemic control and reduce the risk of vascular complications in patients with type 2 diabetes.
• However, the patient is currently prediabetic, and the decision to start treatment should be based on individual risk factors and medical history.
• Studies such as 4 and 5 have shown that adding other medications like linagliptin or sitagliptin to metformin and pioglitazone can improve glycemic control, but the patient's current prediabetic status and age should be taken into consideration.
• 6 suggests that adding metformin to pioglitazone monotherapy can lead to a decrease in body weight and an improvement in insulin resistance and inflammatory state parameters, which may be beneficial for the patient.

Age and Treatment

• The patient's age (85 years old) is an important factor to consider when deciding on treatment.
• While there is no direct evidence in the provided studies to support or refute treatment in an 85-year-old patient with prediabetes, the patient's medical history and current health status should be carefully evaluated to determine the best course of action.
• It is essential to weigh the potential benefits of treatment against the potential risks and consider the patient's overall health and well-being.