What is the optimal management strategy for diabetes mellitus (DM) in adults over 65 years of age with impaired glucose regulation?

From the Guidelines

The optimal management strategy for diabetes mellitus (DM) in adults over 65 years of age with impaired glucose regulation is to prioritize individualized glycemic control with less stringent A1C targets of 7.5-8.5% and medication regimens that minimize hypoglycemia risk, as recommended by the most recent guidelines 1. This approach is supported by the latest evidence, which emphasizes the importance of avoiding hypoglycemia, falls, and polypharmacy in older adults with multiple comorbidities or limited life expectancy. Some key considerations in managing diabetes in older adults include:

• Using metformin as first-line therapy, with careful consideration of renal function
• Preferring DPP-4 inhibitors or GLP-1 receptor agonists as second-line agents due to their low hypoglycemia risk
• Simplifying insulin regimens, often to basal insulin only, with higher pre-meal and bedtime glucose targets than younger adults
• Regular blood glucose monitoring, particularly when using insulin or sulfonylureas, with medication adjustments made gradually
• Considering the use of continuous glucose monitoring (CGM) and automated insulin delivery systems to improve glycemic outcomes and reduce hypoglycemia risk, as recommended by recent guidelines 1. It is also important to consider the patient's health status, cognitive function, and functional status when establishing individualized glycemic goals, and to periodically adjust these goals as needed 1. Ultimately, the goal of diabetes management in older adults is to prioritize quality of life, minimize treatment burden, and reduce the risk of adverse events, rather than solely focusing on achieving tight glycemic control 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION There is no fixed dosage regimen for the management of diabetes mellitus with glipizide or any other hypoglycemic agent. In elderly patients, debilitated or malnourished patients, and patients with impaired renal or hepatic function, the initial and maintenance dosing should be conservative to avoid hypoglycemic reactions

The optimal management strategy for diabetes mellitus (DM) in adults over 65 years of age with impaired glucose regulation is to use a conservative approach with initial and maintenance dosing to avoid hypoglycemic reactions.

• Initial dose: 2.5 mg for geriatric patients
• Titration: Dosage adjustments should ordinarily be in increments of 2.5–5 mg, as determined by blood glucose response
• Maintenance: Some patients may be effectively controlled on a once-a-day regimen, while others show better response with divided dosing 2

From the Research

Optimal Management Strategy for Diabetes Mellitus in Adults over 65 Years of Age

The optimal management strategy for diabetes mellitus (DM) in adults over 65 years of age with impaired glucose regulation involves a comprehensive approach that considers the patient's functional capacity, cognitive status, and comorbidities.

• A comprehensive geriatric assessment is advisable for identifying glycemic targets and glucose-lowering therapies, focused on patient preferences, needs, and risks 3.
• The therapeutic options for older adults with diabetes are similar to those for the adult population, but pharmacological treatments must be carefully prescribed and monitored to avoid hypoglycemia and drug-drug interactions 3, 4.
• Lifestyle intervention, including diet and exercise, is recommended as first-line treatment for diabetes in older adults and has been shown to improve glycemic control, insulin sensitivity, and physical function 5.
• Glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 (SGLT2) inhibitors have been found to be effective in reducing the risk of major adverse cardiovascular events and body weight in older adults with type 2 diabetes 6.
• Insulin therapy remains a mainstay of diabetes management in the inpatient setting, but the optimal glycemic targets during hospital stay are uncertain 4.
• The treatment modality should be determined by the patient's functional capacity, rather than age, and intensive insulin therapy may be beneficial in both type 1 and type 2 diabetes in older adults 7.

Key Considerations

• Patient-centered care: The management strategy should be tailored to the individual patient's needs, preferences, and risks.
• Comprehensive geriatric assessment: This assessment is essential for identifying glycemic targets and glucose-lowering therapies.
• Careful medication management: Pharmacological treatments must be carefully prescribed and monitored to avoid hypoglycemia and drug-drug interactions.
• Lifestyle intervention: Lifestyle intervention, including diet and exercise, is recommended as first-line treatment for diabetes in older adults.
• Novel glucose-lowering medications: GLP-1RAs and SGLT2 inhibitors have been found to be effective in reducing the risk of major adverse cardiovascular events and body weight in older adults with type 2 diabetes.