Diabetes is highly prevalent among patients aged 65 and older. However, optimal glucose management in this population is not well defined. Most of the evidence used for deciding on how aggressively to treat patients with diabetes is based on large, randomized trials that involve younger patients. Although these trials showed that intensive glucose control provides long-term benefits, such as fewer microvascular complications, they also showed that intensive glucose control can cause harm, such as hypoglycemia.
“Although more recent trials have recruited some older patients and individuals with comorbidities, few have provided information on how to treat those with type 2 diabetes,” says Kasia J. Lipska, MD, MHS. “Because of this uncertainty, most clinical guidelines suggest providing individualized therapy. Most guidelines recommend that patients with limited life expectancy or complex comorbidities be treated to less aggressive glycemic control targets. Achieving intensive glycemic control in these patients may result in more harm than good.”
Assessing the Situation
For a study published in JAMA Internal Medicine, Dr. Lipska and colleagues tested the hypothesis that relatively healthier and younger patients with diabetes would be treated more aggressively than those with poor health or who were older, based on individualized treatment guidelines. Using a nationally representative dataset of non-institutionalized patients with diabetes who were 65 or older, the research team divided the study group into three categories:
- Very complex/poor: based on difficulty with two or more activities of daily living or dialysis dependence.
- Complex/intermediate: based on difficulty with two or more instrumental activities of daily living or the presence of three or more chronic conditions.
- Relatively healthy: if none of the above were present.
The study findings did not match the researchers’ hypothesis. “The majority of older patients were treated to an aggressive A1C target of less than 7%,” says Dr. Lipska. “We observed no differences in the proportion of people who reached that target according to the three health status categories.” Additionally, no differences were found in the use of insulin or sulfonylureas—agents that can cause hypoglycemia—according to health status in those who reached those aggressive targets.
“Importantly, we found little evidence to suggest that physicians were individualizing treatment for older patients,” Dr. Lipska explains. “That said, accruing evidence has shown that aggressive targets often do not result in net benefits for older patients with multiple comorbidities and limited life expectancy. They may actually cause harm, including severe hypoglycemia.”
Dr. Lipska emphasizes that insulin and sulfonylureas have a place in the treatment regimen of older patients with diabetes. However, the aggressive targets these medicines are used to reach in this population should be relaxed.
“Although achieving a single glycemic target for all patients with diabetes is an attractive paradigm, there are no shortcuts when it comes to diabetes management,” says Dr. Lipska. “Each patient, regardless of age or comorbidities, needs to be treated on an individual basis. To do so requires time because clinicians need to develop collaborative relationships with patients. They also need to have extensive discussions about what makes sense for each patient’s unique situation.”
Dr. Lipska adds that patients should be heavily engaged in these discussions. Many decisions rely on patient preferences and experiences with their burden of treatment, she says. “These factors must be incorporated into decisions on how aggressively to pursue glycemic control.”
Lipska K, Ross J, Miao Y, et al. Potential overtreatment of diabetes mellitus in older adults with tight glycemic control. JAMA Intern Med. 2015;175:356-362. Available at http://archinte.jamanetwork.com/article.aspx?articleid=2089233.
Selvin E, Coresh J, Brancati F. The burden and treatment of diabetes in elderly individuals in the U.S. Diabetes Care. 2006;29:2415-2419.
Greenfield S, Billimek J, Pellegrini F, et al. Comorbidity affects the relationship between glycemic control and cardiovascular outcomes in diabetes: a cohort study. Ann Intern Med. 2009;151:854-860.
Geller A, Shehab N, Lovegrove M, et al. National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations. JAMA Intern Med. 2014;174:678-686.