What anti-diabetic medications cause hypoglycemia in older patients?

From the Guidelines

Sulfonylureas, particularly glyburide, and insulin secretagogues such as meglitinides, are the anti-diabetic medications that most commonly cause hypoglycemia in older patients. According to the most recent guidelines, sulfonylureas and other insulin secretagogues are associated with hypoglycemia, bone loss, and fracture risk, and should be used with caution in older adults 1. Insulin, including all formulations, directly lowers blood glucose and can cause severe hypoglycemia if dosed incorrectly or if meals are missed. Sulfonylureas stimulate insulin release from the pancreas regardless of blood glucose levels, making them particularly risky for older adults who may have impaired kidney function, irregular eating patterns, or multiple medications. Some key points to consider when managing diabetes in older adults include:

• Sulfonylureas with a shorter duration of action, such as glipizide, are preferred over longer-acting ones like glyburide, which should be avoided in older adults 1.
• Many antimicrobials, such as fluoroquinolones and sulfamethoxazole-trimethoprim, interact with sulfonylureas to increase the effective sulfonylurea dose, which may precipitate hypoglycemia 1.
• Hypoglycemia in older adults can cause serious consequences, including falls, cognitive impairment, cardiovascular events, and even death, making medication selection and blood glucose targets particularly important in this vulnerable population 1.
• Safer alternatives for older patients include metformin, DPP-4 inhibitors, GLP-1 receptor agonists, and pioglitazone. It is essential to monitor the frequency of hypoglycemia at each visit and adjust medications accordingly to minimize the risk of hypoglycemia in older adults 1.

From the FDA Drug Label

Hypoglycemia: All sulfonylurea drugs are capable of producing severe hypoglycemia. ... Elderly, debilitated or malnourished patients, and those with adrenal or pituitary insufficiency, are particularly susceptible to the hypoglycemic action of glucose-lowering drugs Hypoglycemia may be difficult to recognize in the elderly, and in people who are taking beta-adrenergic blocking drugs.

Hypoglycemia: All sulfonylureas are capable of producing severe hypoglycemia. ... Elderly, debilitated or malnourished patients, and those with adrenal or pituitary insufficiency, are particularly susceptible to the hypoglycemic action of glucose-lowering drugs Hypoglycemia may be difficult to recognize in the elderly and in people who are taking beta-adrenergic blocking drugs.

Hypoglycemia: All oral blood glucose-lowering drugs including repaglinide are capable of producing hypoglycemia. ... Hepatic insufficiency may cause elevated repaglinide blood levels and may diminish gluconeogenic capacity, both of which increase the risk of serious hypoglycemia Elderly, debilitated, or malnourished patients, and those with adrenal, pituitary, hepatic, or severe renal insufficiency may be particularly susceptible to the hypoglycemic action of glucose-lowering drugs.

The anti-diabetic medications that can cause hypoglycemia in older patients are:

• Glipizide 2
• Glyburide 3
• Repaglinide 4 These medications can produce severe hypoglycemia, and elderly patients are particularly susceptible to the hypoglycemic action of these drugs. Hypoglycemia may be difficult to recognize in the elderly, especially when taking beta-adrenergic blocking drugs.

From the Research

Anti-Diabetic Medications Causing Hypoglycemia in Older Patients

• Insulin and sulfonylureas are closely associated with an increased risk of hypoglycemia in older patients, as stated in the study 5.
• The use of insulin, especially insulin analogs, may be appropriate in elderly individuals, but it requires careful consideration and monitoring due to the high prevalence of comorbidities and cognitive impairment 6.
• Other glucose-lowering agents may also contribute to the risk of hypoglycemia, although there is limited evidence on their use in elderly adults 6, 7.

Factors Contributing to Hypoglycemia Risk

• Comorbidities, such as renal, cardiovascular, or hepatic concerns, can increase the risk of hypoglycemia in older patients 6, 5.
• Polypharmacy, cognitive impairment, and age-related physiologic changes can also contribute to the risk of hypoglycemia 6, 5, 8.
• Inadequate nutrition and declining cognitive function can further increase the risk of hypoglycemia in older adults 8.

Prevention and Treatment Strategies

• Individualizing glycosylated hemoglobin (HbA1c) targets based on life expectancy, functional status, and individual goals can help minimize the risk of hypoglycemia 6.
• Close monitoring of insulin and sulfonylureas, as well as deprescribing, should be routinely considered in older patients at high risk for hypoglycemia 5.
• Nurses play a crucial role in assessing for hypoglycemia and educating older adults with type 2 diabetes on its prevention 8.