Diabetes Dialogues Discussions – 3D Conference
Thank you chairperson thank you dr. vijay kumar for inviting me so this is the definition of who is elderly the according to you know it is more than 65 years whereas in the indian constance s it is more than sixty years and 30% of our diabetic patients are about the age of 65 years and it is believed that type-2 diabetes in the elderly is now an epidemic almost
60% of the type 2 diabetic patients worldwide are more than 60 years of age and they form a very heterogeneous group some of them are healthy working individuals some of them are functionally and cognitively frail and some of them are nurse in nursing homes better than and the pharmacokinetics also varies in elderly patients there is a variable degree of insulin
Deficiency the peripheral insulin and hepatic insulin resistance is higher in elderly patients and there is altered absorption distribution and elimination of insulin and they are more flown for i po glycemia that is one important reason why you choose a proper drug in the treatment of elderly patients so what are the challenges you face when treating elderly
Type 2 diabetic patient hypoglycemia is the most important challenge it increases the number of adverse events there is a chance for increased fall and fractures polypharmacy most of these patients are going to be on drugs for other comorbid conditions and there will be drug interactions renal impairment is common in elderly people with long-standing diabetes
And interactions with coexisting comorbidities like cardiovascular disease and heart failure cost is very important especially those patients who do not have social support and the quality of life is decrease and there is increased mortality so the endeavor should be to choose a drug which takes care of all these factors and most important which does not
Produce hypoglycemia so the combination of hyperglycemia and hypoglycemia blood sugar swinging between between extremes ultimately leading to lie simic variability can be very fatal in type 2 diabetic patients so what does the world body say so they radiate this year says you take into consideration certain parameters like the risk of hypoglycemia and adverse
Side effects this is duration life expectancy important comorbidities established vascular complications patient attitude that is very important and expected treatment effects and resources and support system if these parameters are not present you can still aim for a1c of seven point five lesson seven point five if any are one or more of these parameters
Are present then don’t try to aggressively treat elderly patients trying to fix you a target above evens eight that will be safer in these elderly patients there are a number of guidelines they are all confusing but we will go by the ada a guideline given this year functionally independent the target should be less than seven point five functionally dependent
The target should be less than eight and lower life expectancy with comorbid conditions you can add anything about eight up to 8.5 or even nine so the again the standard of medical care in diabetes this year has given three important points one it says in older adults an increased risk of hypoglycemia medication classes with low risk of hypoglycemia or prefer
Over treatment of diabetes is common in older adults and should be avoided the intensification or simplification of complex regiments is recommended to reduce a risk of hypoglycemia if it can be done within the individualized a1c target so these are awesome three important cardinal points you must keep in mind when treating elderly type 2 diabetic patient so
What are the considerations when you select a drug for a elderly patient one you have to take into consideration that the impairment of carbohydrate tolerance with aging there is disorderly insulin release reduced insulin production reduced glp-1 secretion altered life it metabolism there is sarcopenia wastage of muscle mass and there is physical inactivity so
Effective anti-diabetic therapy with relatively low risk of hypoglycemia and low glucose variability is very important in elderly diabetic patient so the question to be answered when you choose a drug after metformin what is a trial most of the recommendations say you take into consideration two important points whether the patient has cardiovascular disease
Existing cardiovascular disease our risk of cardiovascular disease or yes renal disease so these two points will decide which drug you choose for the treatment of type 2 diabetic patients so what happens when metformin alone is not able to control the a1c to bring it down to target levels virtually theoretically speaking you can use any of the drugs that
Are available it can be sulfonylurea especially the modern sulfonylureas dpp-4 inhibitors by even pioglitazone can be given and sglt2 inhibitors of course the latest addition but again you have to understand that good medicine is not the same option for all and treatment must be personalized according to each patient needs in elderly patients so you have to
Take into consideration the cvv ot trials you have to understand the dpp-4 inhibitors are cv neutral sglt2 inhibitors have shown a superiority so these consideration will again fail in your consideration when choosing a drug for elderly patients now let us look at dpp-4 inhibitors the subject of topic today talk today so the gp p dpp-4 inhibitors are glucose
Dependent insulin or tropic drugs so they do not increase the insulin levels when there is no high blood sugar so they do not produce hypoglycemia they are capable efficacious of reducing a1c even when the a1c is more than eight they are excellent tolerability profile there is low risk of hypoglycemia and they are very safe in renal impairment now let us see
Trucks will develop team has been tried in patients who are more than 75 years as the study shows with a1c reduction of almost one person a fasting blood sugar reduction of almost 22 milligram person and it was very tolerated in type 2 diabetic patients with very minimal hyperglycemia and another study where individualized targets were taken into consideration
Again almost 50% of the patients achieved individualized targets when treated with will developed in gain addition of will decrypting to metformin the a1c reduction was a very reverse there was no hypoglycemia another important limiting factor in the management of type 2 diabetes weight gain was also not there when wildenstein was added to metformin there
Was minimal risk of hypoglycemia when will decrypting was given to those patients who are on insulin and another important advantage is that there was a reduction in insulin requirement in those patients who were given will that dip in when they are already on insulin they were on foot in fact will developed in certain it almost 40 percent reduction in daily
Insulin requirement so you can reduce the dose of insulin when you add will decrypt into those patients who are on insulin gang will – lipton has been shown to be very safe in those patients who are fasting during ramadan next week the ramadan fasting will start many of these are muslim brothers elderly patients are going too fast and it has been shown it is
One of the best drug for treatment during ramadan to avoid eiper glycemia what about the other drugs linagliptin in elderly population again this is a study where more than 4,000 patients were studied which included almost thousand 300 patients who were more than 65 years of age and the results showed that linagliptin was as effective and as safe as it is in
Those patients who are less than 65 years similarly this is a long-term prospective study 24 months with sitagliptin again it was shown that the tag leptin is effective and there is a durability with reference to if you rely semuc efficacy with this drug and as i told you when are you problem associated with increased cardiovascular morbidity and mortality is
Glycemic variability it has been shown that will that lipton induce better circadian glucose control than other drugs they have been reducing the glycemic variability which increases cardiovascular morbidity and mortality ryan we all know that the ethnic kidney disease is a major burden in elderly patients especially with longer duration of diabetes and this
Again he’s shown it has been shown that only two drugs are safe in those patients who have moderate to severe diabetic kidney disease insulin and dpp-4 inhibitors but again with insulin there is always a possibility of hypoglycemia whereas with the bpp for inhibitors the chances of hyperglycemia is very minimal we as shown in this study will decrypt him in type
2 patients who are more than 75 years with moderate to severe renal involvement it shows that the a1c reduction is almost again one person with only 50 gram of lifting you can give only 50% of the recommended dose still achieve the same a 1c reduction without hypoglycemia so in even in severe live t kidney disease you can still give dpp-4 inhibitors another area
Where dpp-4 inhibitors are very useful using cardiovascular disease one of the criticisms are what will decrypting is that there is no prospective cardiovascular outcome trials but a large amount of rcts and real world experience again as clearly showed that will that lipton is cardiovascular neutral with reference to three point mates so the mains composite
Endpoint myocardial infarction stroke cardiovascular death all have been shown to be not increased when treated with a will decrypting last year the carmelina study which is a cv outcome study with linagliptin again showed that the patients can be safely treated with linagliptin without any increase in cardiovascular morbidity and mortality heart failure is
Becoming a very important problem in elderly patients in type 2 diabetes though there are some red flags about sex uplifting it has been shown that will does lifting again can be safely used in those patients who are at risk heart failure so there is lower risk of heart failure with with buildig lipton so ladies and gentlemen the take home may say today’s the
Prevalence of diabetes is rising in the more than 65 years age group the challenges include heterogeneity hypoglycemia is complications polypharmacy spaz clinical data different goals of therapy ami an individual goal to preserve quality of life and avoid side effects of therapy is a key in management dpp-4 inhibitors are with the best choice already in type
2 diabetic patients that is robust clinical evidence in elderly minimal risk of hypoglycemia glycemic variability is taken care of cardiovascular benefit including heart failure with will decrypting and safe in renal impairment thank you very much
Transcribed from video
Managing elderly diabetics with DPP IV i – Dr R Madhavan By Diabetes Dialogues Discussions 3D Conference