From the Guidelines
For an 82-year-old female diabetic with heart problems who is currently on Actos 30mg and Farxiga 5mg, a safer alternative would be a DPP-4 inhibitor such as Sitagliptin (Januvia) 100mg once daily, as recommended by the 2020 European Society of Cardiology guidelines on diabetes, pre-diabetes, and cardiovascular diseases 1. Sitagliptin would be more appropriate given her age and cardiac history, as it has a neutral cardiovascular profile and lower risk of heart failure compared to Actos (pioglitazone), which carries a black box warning for congestive heart failure.
With an A1c of 6.5 and blood sugars mostly controlled (though with some elevations to 180-250), Sitagliptin would help maintain glycemic control without the fluid retention risks of Actos. The combination of Sitagliptin with her current Farxiga (an SGLT2 inhibitor) would provide complementary mechanisms of action - Farxiga increases glucose excretion through the kidneys while Sitagliptin enhances insulin secretion and reduces glucagon.
This combination is particularly beneficial for elderly patients as it carries minimal hypoglycemia risk, which is important given her current absence of hypoglycemic episodes. According to the American College of Physicians guidance statement on HbA1c targets for glycemic control with pharmacologic therapy in nonpregnant adults with type 2 diabetes mellitus, clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes, and consider deintensifying pharmacologic therapy in patients who achieve HbA1c levels less than 6.5% 2.
The patient should continue regular blood glucose monitoring and follow up with her physician within 1-2 months to assess the effectiveness of this medication change. Additionally, the patient's life expectancy and comorbid conditions should be taken into account when determining the target HbA1c level, as recommended by the American College of Physicians guidance statement 2.
Some key points to consider when making this medication change include:
- Sitagliptin has a neutral cardiovascular profile and lower risk of heart failure compared to Actos
- The combination of Sitagliptin and Farxiga provides complementary mechanisms of action and minimal hypoglycemia risk
- The patient should continue regular blood glucose monitoring and follow up with her physician to assess the effectiveness of the medication change
- The patient's life expectancy and comorbid conditions should be taken into account when determining the target HbA1c level.
From the FDA Drug Label
A determination has not been made whether controlled clinical studies of glipizide included sufficient numbers of subjects aged 65 and over to define a difference in response from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.
A safer alternative to Actos 30mg PO for an 82-year-old female diabetic with heart problems is Glipizide, considering her A1c level of 6.5 and concomitant use of Farxiga 5mg. Key points to consider:
- Dose selection: Start at the low end of the dosing range due to potential decreased hepatic, renal, or cardiac function.
- Cardiac function: The patient's heart problems should be taken into account when selecting a dose.
- Concomitant disease or other drug therapy: Consider potential interactions with other medications, such as Farxiga.
- Monitoring: Closely monitor blood sugar levels, as the patient's range is 70-180, and 8% of the time 180-250, with no hypoglycemic episodes reported 3.
From the Research
Safer Drug Alternatives for an 82-Year-Old Female Diabetic with Heart Problems
The patient's current medication, Actose 30mg po, may not be the most suitable option due to her age and health conditions. Considering her A1c level of 6.5, blood sugar ranges, and the fact that she takes Farxiga 5mg, a safer alternative can be explored.
- The study 4 suggests that metformin should be avoided in patients over 80 years of age due to declining kidney function. However, this study does not directly address the patient's current medication, Actose.
- The study 5 compares the efficacy of 12 single-drug regimens for the treatment of type 2 diabetes mellitus. It finds that Liraglutide may be more effective than other treatments, including Glimepiride, Pioglitazone, Sitaglitin, Exenatide, and Glipizide, at reducing glycated hemoglobin (HbA1c) levels.
- Given the patient's heart problems, it is essential to consider the potential interactions between diabetes medications and heart conditions. The study 6 discusses the treatment of heart failure in older persons with coexisting conditions, including diabetes mellitus. It emphasizes the importance of good glycemic control, treatment of hypertension and dyslipidemia, and the use of diuretics, angiotensin-converting enzyme inhibitors, and beta blockers.
Potential Alternatives to Actose
Based on the available evidence, potential alternatives to Actose 30mg po for this patient could be:
- Liraglutide, as it has been shown to be effective in reducing HbA1c levels 5
- Other medications that are not contraindicated in patients with heart problems and diabetes, such as Glimepiride or Pioglitazone, although their efficacy may be lower compared to Liraglutide 5
It is crucial to consult with a healthcare professional to determine the best course of treatment for this patient, taking into account her individual needs, medical history, and current medications.