Should a 91-year-old female with an elevated hemoglobin A1c (HbA1c) level of 7.8% start medication for hyperglycemia?

From the Guidelines

For a 91-year-old female with an elevated hemoglobin A1c (HbA1c) level of 7.8%, the American College of Physicians guidance statement suggests that clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid targeting an HbA1c level, as the harms outweigh the benefits in this population 1. Given her advanced age, the focus should be on minimizing symptoms rather than achieving a specific HbA1c target. The guidance statement emphasizes the importance of considering the patient's general health, life expectancy, treatment burden, and costs of care when making decisions about glycemic control. In this case, since the patient's HbA1c level is already close to the recommended range of 7% to 8% for most patients with type 2 diabetes, initiating medication may not be necessary, and the focus should be on monitoring her condition and adjusting her treatment plan as needed to minimize symptoms and avoid hypoglycemia 1. Regular monitoring of her blood glucose levels, kidney function, and potential side effects is essential, with follow-up HbA1c testing in 3 months to assess treatment efficacy. It is also important to consider her overall health status, functional and cognitive impairments, fall risk, ability to adhere to treatment, and medication burden and cost when making decisions about her care. By taking a patient-centered approach and considering the potential benefits and harms of treatment, clinicians can provide high-quality care that prioritizes the patient's quality of life and minimizes the risk of adverse effects. Some key points to consider in her care include:

• Minimizing symptoms related to hyperglycemia
• Avoiding hypoglycemia
• Monitoring kidney function and blood glucose levels regularly
• Adjusting her treatment plan as needed to minimize symptoms and avoid hypoglycemia
• Considering her overall health status, functional and cognitive impairments, fall risk, ability to adhere to treatment, and medication burden and cost when making decisions about her care.

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 general, glipizide tablets should be given approximately 30 minutes before a meal to achieve the greatest reduction in postprandial hyperglycemia. Initial Dose:The recommended starting dose is 5 mg, given before breakfast. Geriatric patients or those with liver disease may be started on 2.5 mg.

The patient is a 91-year-old female, which categorizes her as a geriatric patient. Given her age and elevated HbA1c level of 7.8%, it is reasonable to consider starting medication for hyperglycemia.

• The initial dose for a geriatric patient is 2.5 mg, given before breakfast.
• Monitoring of the patient's blood glucose and glycosylated hemoglobin levels is necessary to determine the minimum effective dose and to detect primary or secondary failure.
• The patient should be informed of the potential risks and advantages of glipizide and the importance of adhering to dietary instructions and a regular exercise program.
• Given the patient's age, it is essential to be cautious of the risk of hypoglycemia and to monitor her closely. 2

From the Research

Hyperglycemia Treatment for a 91-Year-Old Female

• The patient's elevated hemoglobin A1c (HbA1c) level of 7.8% indicates poor blood glucose control 3.
• According to the American Diabetes Association guidelines, the HbA1c target for older adults varies based on their health status 4.
• For healthy older adults, an HbA1c level lower than 7% is recommended, while for those with symptoms of frailty and risks of hypoglycemia, a more relaxed target of less than 8-9% is advised 3.
• A study published in Diabetes Care found that older adults with an HbA1c level of 7% or lower were not at elevated risk of mortality, regardless of their health status 4.
• Another study published in the same journal found that an HbA1c level greater than 8% was associated with increased risk of all-cause and cause-specific mortality in older adults with diabetes 5.

Considerations for Medication

• The decision to start medication for hyperglycemia in a 91-year-old female with an HbA1c level of 7.8% should be individualized, taking into account her overall health status, comorbidities, and risk of hypoglycemia 3, 4.
• Combination therapy with oral antidiabetic medications, such as metformin and sulfonylurea, may be effective in reducing HbA1c levels in older adults with type 2 diabetes 6.
• However, the risk of hypoglycemia and other adverse effects should be carefully considered when initiating or intensifying glucose-lowering therapy in older adults 3, 7.