From the Guidelines
GLP-1 receptor agonists, such as liraglutide (Victoza) or semaglutide (Ozempic), can be used in elderly patients with type 2 diabetes, but with careful consideration of their individual needs and potential risks. When prescribing GLP-1 receptor agonists to elderly patients, clinicians should start with lower doses and titrate more gradually than in younger adults, as recommended by recent studies 1. For example, with semaglutide, consider starting at 0.25mg weekly for 4 weeks before increasing to 0.5mg weekly, with careful evaluation before further dose increases. Renal function assessment is essential as these medications are primarily cleared by the kidneys, with dose adjustments needed for patients with eGFR below 30 ml/min, as indicated in the 2020 expert consensus decision pathway on novel therapies for cardiovascular risk reduction in patients with type 2 diabetes 1. Elderly patients should be monitored closely for gastrointestinal side effects like nausea, vomiting, and diarrhea, which can lead to dehydration and electrolyte imbalances, as reported in a narrative review of clinical pharmacology and implications for peri-operative practice 1. The risk of hypoglycemia is lower with GLP-1 agonists compared to insulin or sulfonylureas, but remains a concern when used in combination therapies, as noted in the 2019 update to the management of hyperglycemia in type 2 diabetes 1. Weight loss effects, while beneficial for many patients, should be monitored carefully in frail elderly patients who cannot afford significant weight reduction. Medication adherence challenges related to injection administration should be addressed, potentially involving caregivers in medication management. Treatment goals should be individualized, with less stringent HbA1c targets (7.5-8.5%) often appropriate for elderly patients with multiple comorbidities or limited life expectancy, as suggested in the diabetes management in chronic kidney disease consensus report 1. Regular follow-up every 1-3 months during initiation and dose adjustment is recommended to assess tolerability, efficacy, and potential adverse effects. Some key considerations when using GLP-1 receptor agonists in elderly patients include:
- Starting with lower doses and titrating gradually
- Monitoring renal function and adjusting doses as needed
- Watching for gastrointestinal side effects and managing them appropriately
- Being mindful of the risk of hypoglycemia, especially when used with other diabetes medications
- Individualizing treatment goals and HbA1c targets based on the patient's overall health and life expectancy. Overall, GLP-1 receptor agonists can be a valuable treatment option for elderly patients with type 2 diabetes, but require careful consideration and monitoring to ensure safe and effective use, as supported by the most recent evidence from 2022 1.
From the FDA Drug Label
In the pool of placebo- and active-controlled glycemic control trials, 744 (23.6%) OZEMPIC-treated patients were 65 years of age and over and 102 OZEMPIC-treated patients (3.2%) patients were 75 years of age and over. In SUSTAIN 6, the cardiovascular outcome trial, 788 (48.0%) OZEMPIC-treated patients were 65 years of age and over and 157 OZEMPIC-treated patients (9. 6%) patients were 75 years of age and over. No overall differences in safety or efficacy were detected between these patients and younger patients, but greater sensitivity of some older individuals cannot be ruled out. No specific considerations for using GLP-1 receptor agonists, such as semaglutide or liraglutide, in elderly patients with type 2 diabetes mellitus are provided in the label, other than the information that no overall differences in safety or efficacy were detected between elderly patients and younger patients. Key considerations for the use of GLP-1 receptor agonists in elderly patients include:
- Monitoring for potential adverse effects, such as hypoglycemia, acute kidney injury, and hypersensitivity reactions.
- Considering the potential for greater sensitivity of some older individuals to the medication.
- Weighing the benefits and risks of treatment in this population, as the label does not provide specific guidance on dosage adjustments or special precautions for elderly patients 2.
From the Research
Considerations for Using GLP-1 Receptor Agonists in Elderly Patients with Type 2 Diabetes
- The use of GLP-1 receptor agonists, such as liraglutide and semaglutide, in elderly patients with type 2 diabetes mellitus (T2DM) requires careful consideration of the potential benefits and risks 3.
- These agents have been shown to be effective in reducing HbA1c levels and promoting weight loss, with a low risk of hypoglycemia 3, 4.
- However, gastrointestinal adverse events, such as nausea, are common with GLP-1 receptor agonists 3, 5.
Efficacy and Safety in Elderly Patients
- Studies have demonstrated that GLP-1 receptor agonists can be effective and well-tolerated in elderly patients with T2DM, including those aged 80 and over 6.
- The use of GLP-1 receptor agonists in this population may reduce the need for agents associated with hypoglycemia, such as sulfonylureas and insulin 6.
- Semaglutide, in particular, has been shown to be safe and effective in adults and elderly patients with renal or hepatic disorders, with no dose modification required 5.
Combination Therapy with Basal Insulin
- The use of GLP-1 receptor agonists in combination with basal insulin may be a viable treatment option for elderly patients with T2DM who require more intensive glucose control 7.
- The fixed-ratio combination of insulin glargine and lixisenatide has been studied in older patients with T2DM, with promising results 7.
Cardiovascular Benefits
- GLP-1 receptor agonists, including semaglutide, have been shown to have cardiovascular benefits, reducing the risk of major adverse cardiovascular events in patients with established cardiovascular disease 4, 5.
- This may be an important consideration in the management of elderly patients with T2DM, who are at increased risk of cardiovascular complications.