Diabetes in Older People : A common problem but (?) Different Strategies Dr B. Manivannan FRCP Consultant Physician and Geriatrician Moseley Hall Hospital and BMI Priory Hospital

How Common? 3.2 million patients with diabetes in the UK 90% type 2, 10 % type 1 Approx 37 % over 70 ( 24% 70-79, 13% 80+) Approx 63 % over 60 1 in 4 residents in Care homes

Why Different strategies ? Most principles of treatment are the same Some important differences in treatment aims and approaches Why? Balancing life expectancy vs Aim of tight glycaemic control More co-morbid conditions and multiple medications

Aim of intense glycaemic control ? Minimising the risk of microvascular and macrovacular complications Mr Marriot is 85. He suffers from type 2 Diabetes; lives alone. Carers x 3 times. Mr Smith is 65. He also suffers from type 2 Diabetes ; lives with his wife ; 3 X holidays per year. Works part time.

Mrs. A.S is a 86 year old lady, living independently on her own. She even goes shopping on the bus. Her only past medical history is that of a right Colles fracture when she slipped and fell on an icy morning in Feb 2012. She is on no medication except co-codamol 8/500 prn. What is the single most beneficial assessment and treatment you would want to consider ?

Older people : multiple co-morbidities Multiple drugs Less appetite Difficulty getting food on time, cooking Loss of muscle and adipose tissue Declining renal function Difficulty recognising symptoms of hypoglycaemia (blunted neuro glycopenic responses)

What is the optimum approach with Mr Marriot? Achieve ‘reasonable’ glycaemic control Prevent hypoglycaemic episodes at ALL costs Prevent repeated and recurrent infections Prevent HHS (HONK)

Number of factors Duration of diabetes Chronological age Biological age and degree of frailty Tendency to hypoglycaemia and degree of hypoglycaemia awareness Social circumstances

What is reasonable glycaemic control? What is ideal or intense glycaemic control?

HbA1c 6.5% - 7% (48-53 mmol/mol) HbA1c 7.0-7.5% (53-58 ) HbA1C 7.5-8.5% (58-69)

Hypoglycamia Dangerous Medical emergency Immediate harm –within minutes :’ here now’ (Hyperglycaemia –not ‘here now’; longer term complications) Hypoglycaemia in the Elderly-even more dangerous Blunted hypoglycaemia awareness

Conscious patient- Unconscious /semi conscious patient Glucagon IM but if no hepatic glycogen stores may not be helpful ( chronic liver disease, cachexia) 20% dextrose now recommended ( 20 % 100 ml stat Iv) and not 50 % destrose

Mr. Lambert is 78 years old; he has suffered from type 2 Diabetes since age 48. He is very health conscious and controlled his diabetes quite well. His wife passed away last year and now lives alone. Currently he is on Metformin 1g bd and Gliclazide 80 mg bd. He is being reviewed in surgery due to increasing falls and confusion. Latest HbA1c is 47.

Treatment of diabetes in Older people Relatively shorter acting drugs Minimal or low risk of hypoglycaemia Awareness of drug metabolism and excretion and co-existing renal and liver dysfunction Simple and gentler once or twice day insulin regimes rather than intensive basal bolus regimes Start low Go slow Treat your patient not the HbA1c !

Metformin Metformin: 60 years in clinical use (1957 to date ) Fit as a fiddle, and indispensable for its pivotal role in type 2 diabetes management: Diabetes Metab 2006 Dec: 32: 555–556 Inhibits hepatic gluconeogenesis Increases insulin sensitivity in muscle and adipose tissue Increases peripheral utilisation of insulin No risk of hypoglycaemia In overweight patients - a vascular protective effect Renal route of excretion; avoid if eGFR less than 30 ( review dose if less than 45) Diarrhoea and GI side effects –start slow ; long term use may cause vit B12 deficiency If having a radiological examination with contrast –omit for atleast 48 hours

Sulfonylureas Most commonly used in UK is Gliclazide Insulin secretagogues- need some pancreatic beta cell activity More potent ( 1.5- 2% reduction in HbA1c) Can cause hypoglycaemia (sometimes profound hypoglycaemia) In elderly use at lower doses 40-80 mg od/bd Hepatic route of excretion for Gliclazide but has renal metabolites Weight gain a disadvantage

Gliptins or Dipeptidyl peptidase-4 (DPP-4) Inhibitors Inhibits the action of DPP 4 ( DPP 4 breaks down incretin) The levels of incretin (GLP1 and GIP ) thus rises Incretin mimic Incretins stimulate glucose dependant insulin release and inhibit glucagon release Slow gastric emptying and promote satiety Saxagliptin, Sitagliptin, Linagliptin, Vildagliptin, Alogliptin Low risk of hypoglycaemia No weight gain Well tolerated even in older people Gentle drugs , HbA1c reduction approx 0.5%-1%

GLP 1 Analogues or Agonists Also incretin mimics stimulates glucose dependent insulin Suppresses inappropriate glucagon secretion Slows gastric emptying Promotes satiety Exanetide bd or once weekly Liraglutide once daily –can be taken independent of meal time Lixisenatide, Albiglutide, Dulaglutide

GLP 1 receptor agonists More potent than the gliptins ; Approx 1% HbA1c Low risk of hypoglycaemia (unless combined with a sulphonyurea) Weight loss or atleast maintenance Injectable preparations Can be used in the elderly Clinical context : ‘young’ elderly, overweight

Sodium –Glucose Co Transport Inhibitors (SGLT2 inhibitors) Action independent of insulin Block re absorption of glucose in proximal renal tubule Low risk of hypo (unless in combination) Canagliflozin, Dapagliflozin, Empagaflozin Dapagliflozin not recommended age over 75 EGFR atelast 45 Tendency to more UTIs, genital fungal infections, pollakiuria Very new – medium and long term FU still to come

Insulin in Older people Start low-go slow Get to know a few insulins across the duration of action ( short, intermediate and long/basal) well Twice daily regimes quite common In frail and carer/DN needed –once daily Analogue Insulins vs Human Insulins Biosimilar analogue insulins ( eg; Lantus Abasglar etc for Insulin Glargine

Treatment of diabetes in Older people- Summary Relatively shorter acting drugs Minimal or low risk of hypoglycaemia Awareness of drug metabolism and excretion and co-existing renal and liver dysfunction Simple and gentler once or twice day insulin regimes rather than intensive basal bolus regimes Start low Go slow Treat your patient not the HbA1c !

Thank you