What are the recommendations for a 92-year-old patient with type 2 diabetes (T2D)?

From the Guidelines

For a 92-year-old patient with type 2 diabetes, I recommend a conservative management approach with an A1C target of 7.5-8.5% rather than stricter control, prioritizing quality of life and minimizing hypoglycemia risk. This approach is supported by the most recent and highest quality study, which emphasizes the importance of patient-centered care and individualized treatment plans 1.

Initial Therapy

Start with metformin at a low dose of 500 mg daily with meals, gradually increasing to 500 mg twice daily as tolerated, after checking kidney function, as metformin is the preferred initial pharmacologic agent for type 2 diabetes, according to the American Diabetes Association standards of medical care in diabetes 1.

Combination Therapy

If metformin is contraindicated or insufficient, consider DPP-4 inhibitors like sitagliptin (25-100 mg daily based on kidney function) as they have minimal hypoglycemia risk, and avoid sulfonylureas due to hypoglycemia risk, as recommended by the standards of medical care in diabetes 1.

Physical Activity

Physical activity should be gentle and appropriate for age, such as short walks or seated exercises, with a goal of at least 150 minutes per week of moderate-intensity aerobic activity, as recommended by the standards of medical care for type 2 diabetes in China 2019 1.

Monitoring and Complications

Regular monitoring for complications is essential, with particular attention to kidney function, vision, and foot health, as emphasized by the American Diabetes Association standards of medical care in diabetes 1.

Diet

Focus on diet with moderate carbohydrate restriction, regular small meals, and adequate protein intake, as recommended by the nutrition recommendations and interventions for diabetes position statement of the American Diabetes Association 1.

This conservative approach balances diabetes management with quality of life and minimizes hypoglycemia risk, which is particularly dangerous in the elderly and can lead to falls, cognitive impairment, and cardiovascular events, as supported by the most recent and highest quality study 1.

From the FDA Drug Label

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 Geriatric patients or those with liver disease may be started on 2.5 mg. The recommended starting dose is 5 mg, given before breakfast. Dosage adjustments should ordinarily be in increments of 2.5–5 mg, as determined by blood glucose response.

For a 92-year-old patient with type 2 diabetes, the recommended initial dose of glipizide is 2.5 mg, given before breakfast, due to the patient's age.

• The dose should be conservative to avoid hypoglycemic reactions.
• Dosage adjustments should be made in increments of 2.5-5 mg, based on blood glucose response.
• The patient should be closely monitored for signs of hypoglycemia.
• It is also important to consider the patient's renal and hepatic function when determining the dose.
• The patient's diet and exercise regimen should also be taken into account when managing their diabetes 2.

From the Research

Patient Profile

• Age: 92 years old
• Condition: Type 2 diabetes

Management Considerations

• According to 3, dietary management plays a less significant role in older diabetic patients, but exercise, particularly focusing on balance and stability, is crucial for their management and treatment.
• The use of metformin should be avoided in patients over 80 years of age due to declining kidney function, as stated in 3.
• Insulin therapy is an option, but patients should be monitored carefully for hypoglycemia, which is related to advancing age, as mentioned in 3.

Treatment Options

• Combination therapy with metformin and sulfonylurea is a widely used treatment, but its effects compared to other antidiabetic medications are still controversial, as discussed in 4.
• The addition of a dipeptidyl peptidase-4 (DPP-4) inhibitor to metformin and sulfonylurea therapy may result in substantial glucose-lowering effects, as shown in 5.
• Sodium-glucose cotransporter 2 (SGLT2) inhibitors have additional benefits, including weight loss, blood pressure reduction, and cardiovascular risk reduction, making them a potential option for add-on therapy to metformin, as suggested in 6.

Safety Considerations

• Sulfonylureas as add-on therapy to metformin are associated with an increased risk of all-cause mortality and major hypoglycemic episodes compared to other oral hypoglycemic agents, as found in 7.
• SGLT2 inhibitors have an increased risk of urogenital infections and possible risk of "euglycaemic" diabetic ketoacidosis, as mentioned in 6.