From the Guidelines
Rybelsus (semaglutide) is not recommended for an 89-year-old with an A1C of 9.4 due to the patient's advanced age and potential for increased risk of hypoglycemia and other adverse effects, as suggested by the American College of Physicians guidance statement 1. Instead, the focus should be on minimizing symptoms related to hyperglycemia and avoiding targeting a specific HbA1c level, as the harms of intensive glycemic control may outweigh the benefits in this population 1. The patient's kidney function, fall risk, cognitive status, and ability to maintain proper hydration should be assessed, and a comprehensive geriatric assessment and discussion about treatment goals is recommended before initiating any therapy 2. Less stringent A1C targets (around 8-8.5%) may be more appropriate for very elderly patients to avoid hypoglycemia risks, and metformin may be considered as a first-line treatment for type 2 diabetes due to its effectiveness, safety, and low cost 3. Regular monitoring for hypoglycemia and other adverse effects is essential, especially if the patient is on other diabetes medications. The medication plan should be individualized, and the patient's preferences, general health, and life expectancy should be taken into account when making treatment decisions 1. In general, the goal should be to balance the benefits and harms of treatment and to prioritize the patient's quality of life and safety.
From the Research
Treatment Options for Type 2 Diabetes
- The American Association of Clinical Endocrinologists and the American Diabetes Association recommend considering insulin administration for people with type 2 diabetes with HbA1c levels exceeding 9.0% and 10%, respectively 4.
- However, studies suggest that glucagon-like peptide-1 (GLP-1) receptor agonists may offer superior benefit to insulin in reducing HbA1c levels, especially in patients with higher baseline HbA1c levels 4, 5.
- A study comparing semaglutide, a GLP-1 analogue, with insulin glargine found that semaglutide resulted in greater reductions in HbA1c and weight, with fewer hypoglycemic episodes 5.
Considerations for Older Adults
- A study evaluating type 2 diabetes medication management and control in older adults found that patients 80 to 89 years of age required fewer diabetic medications to achieve similar glycemic control compared to younger patients 6.
- The study also found that metformin, glucagon-like peptide-1 agonists, insulin glargine/detemir, and short-acting insulin were more frequently prescribed in younger patients compared to older patients 6.
Rybelsus (Semaglutide) as a Treatment Option
- Rybelsus is an oral GLP-1 receptor agonist that has been shown to be effective in reducing HbA1c levels and weight in patients with type 2 diabetes 5, 7.
- However, there is limited information available on the use of Rybelsus in patients with HbA1c levels as high as 9.4%, especially in older adults.
- Considering the patient's age (89 years) and HbA1c level (9.4%), it is essential to weigh the potential benefits and risks of Rybelsus treatment, including its efficacy, safety, and potential interactions with other medications.
Other Treatment Options
- Other treatment options, such as insulin, sulfonylureas, dipeptidyl peptidase-4 (DPP-4) inhibitors, and thiazolidinediones, may also be considered for this patient, depending on their individual needs and medical history 4, 7, 8.
- A systematic review and meta-analysis found that insulins, DPP-4 inhibitors, GLP-1 analogues, and thiazolidinediones all produced statistically significant reductions in HbA1c in combination with metformin and a sulphonylurea 8.