From the Guidelines
Old age alone is not a contraindication to using SGLT2 inhibitors such as empagliflozin, canagliflozin, dapagliflozin, and ertugliflozin. These medications can be prescribed to older adults with type 2 diabetes, but require careful consideration of individual patient factors. When prescribing SGLT2 inhibitors to elderly patients, start with the lowest effective dose and monitor kidney function closely, as older adults often have reduced renal function 1. Be particularly vigilant about volume status, as these medications increase urination and can lead to dehydration and hypotension, which elderly patients are more susceptible to experiencing. Assess fall risk, as orthostatic hypotension may be more pronounced in older adults. Also consider polypharmacy issues common in elderly patients, watching for potential drug interactions. SGLT2 inhibitors work by preventing glucose reabsorption in the kidneys, leading to increased glucose excretion in urine, which helps lower blood glucose levels independent of insulin. This mechanism remains effective regardless of age, though the overall benefit-risk profile should be individually assessed in elderly patients, particularly those who are frail or have multiple comorbidities. Some key considerations include:
- Monitoring for signs of volume depletion, such as orthostatic hypotension and dehydration 1
- Assessing the risk of genital mycotic infections and urinary tract infections 1
- Considering the potential for increased risk of osteoporotic bone fractures 1
- Educating patients on the potential adverse effects of SGLT2 inhibitors, including modest volume contraction, blood pressure reduction, and weight loss 1 It is essential to weigh the benefits and risks of SGLT2 inhibitors in older adults, taking into account their individual health status, comorbidities, and potential for drug interactions 1.
From the Research
SGLT2 Inhibitors in Older Adults
- Old age is not a contraindication to using Sodium-Glucose Linked Transporter 2 (SGLT2) inhibitors, as they have been shown to be effective and safe in older adults with type 2 diabetes 2, 3.
- Randomized clinical trials have demonstrated the safety and tolerability of SGLT2 inhibitors in older adults, with benefits including reduced glycated hemoglobin and body mass index values 3.
- However, caution is recommended when using SGLT2 inhibitors in fragile elderly patients and those with chronic kidney disease, due to potential risks such as volume depletion, hypoglycemia, genital infections, and diabetic ketoacidosis 2, 4, 5.
Safety Considerations
- The risk of adverse effects associated with SGLT2 inhibitors, such as urinary tract infections and worsening renal function, can be minimized with appropriate patient selection, education, and monitoring 2, 3.
- SGLT2 inhibitors have been shown to be well-tolerated and safe in older adults, with a low risk of hypoglycemia and no increased risk of malignancy 3, 5.
- However, the risk of amputations and fractures associated with canagliflozin, a type of SGLT2 inhibitor, requires further study and caution 5.
Benefits in Older Adults with Heart Failure and Chronic Kidney Disease
- SGLT2 inhibitors have been shown to reduce the combined risk of heart failure hospitalizations or cardiac death and preserve renal function in older adults with heart failure and chronic kidney disease 6.
- The use of SGLT2 inhibitors in this population may provide clinical benefits and improve outcomes, although further study is needed to confirm these findings 6.