1. Management of Diabetes in the Older Person
Nicola Zammitt
CD ECED
Secondary care lead Diabetes MCN
30/3/17

2. Outline of workshop What are the benefits of tight glycaemic control?
Is tight glycaemic control a bad thing?
What will make a difference to life expectancy?
Are there guidelines/targets for older people?
Which drugs should we choose?
What else would anyone like to discuss?

3. Benefits of tight glycaemic control
Relief of symptoms
Reduction of complications
UKPDS 33
Lancet 1998

4. Benefits of tight glycaemic control
Relief of symptoms
Reduction of complications
UKPDS 33
Lancet 1998
Time since randomisation (yrs)

5. Benefits of tight glycaemic control
Relief of symptoms
Reduction of complications
UKPDS 33
Lancet 1998
Time since randomisation (yrs)

6. Benefits of tight glycaemic control
Relief of symptoms
Reduction of complications
UKPDS 33
Lancet 1998

7. Benefits of tight glycaemic control
Relief of symptoms
Reduction of complications
UKPDS 10 yr FU
NEJM 2008

8. Benefits of tight glycaemic control
Relief of symptoms
Reduction of complications
UKPDS 10 yr FU
NEJM 2008

9. Benefits of tight glycaemic control
Relief of symptoms
Reduction of complications
UKPDS 10 yr FU
NEJM 2008

10. Benefits of tight glycaemic control
Relief of symptoms
Reduction of complications
UKPDS 10 yr FU
NEJM 2008

11. Benefits of tight glycaemic control
Relief of symptoms
Reduction of complications
UKPDS 10 yr FU
NEJM 2008
Loss of HbA1c between-group differences
“Legacy effect”
? Benefits of early control

12. Benefits of tight glycaemic control
Relief of symptoms
Reduction of complications
Evidence of benefit for microvascular disease
? Legacy effect for macrovascular disease
Long time to see benefits (esp macrovascular)
Patient age
Comorbidities
What complications are we trying to prevent?

13. Hypoglycaemia in type 2 DM
Risk of hypo increases with increasing insulin deficiency and duration of insulin treatment
Regardless of treatment modality, intensive therapy associated with increased risks of hypo
Insulin-deficient patients with T2DM can develop syndromes such as IHA and HAAF
IHA increases risk of SH.
Older patients are at increased hypo risk as a result of diminished symptoms and altered thresholds for counterregulatory responses
Knowledge of hypoglycaemia is poor in the elderly and their relatives
1. Leese GP, Wang J, Broomhall J, Kelly P, Marsden A, Morrison W, et al. Frequency of severe hypoglycemia requiring emergency treatment in Type 1 and Type 2 diabetes: a population-based study of health service resource use. Diabetes Care 2003;(1176):1180.
2. Donnelly LA, Morris AD, Frier BM, Ellis JD, Donnan PT, Durrant R, et al. Frequency and predictors of hypoglycaemia in type 1 and insulin-treated type 2 diabetes: a population based study. Diabetic Medicine 2005;22:

14. Hypoglycaemia in type 2 DM
Study
Hepburn 1993
VA-CSDM, 1995
UKPDS 33, 1998
Henderson, 2003
Leese, 2003
Leiter 2003
Donnelly, 2005
Akram, 2006
UK Hypoglycaemia Study Group, 2007
Schopman, 2010
Design
Retrospective questionnaire
Prospective multicentre RCT
Population-based dataset analysis
Retrospective recall of SH
Prospective
Prospective observational multicentre study
Retrospective recall of SH, prospective FU of mild hypos No
104 T1DM, 104 T2DM
153
3935
215
160
335 total; 133 T2DM
94 T1DM 173 T2DM
401
85 T2Ins <2
105 T2 Ins >5
122
Durn
1 year
18-35 months
10 years
I year
Cross-sectional
1 month
One month
All hypos
82.7%
56% conv
93% intsv
36.5%
64% -
72.9%
45%
51% T2 Ins <2
64% T2Ins >5 SH
10% NA
2.3%
15%
7.3%
14.3% 3%
16.5%
7% T2Ins <2
25% T2Ins >5
Overall 9.8%
(NHA 2.7%
IHA 50%)

15. Hypoglycaemia in type 2 DM
25%
22%
UK Hypoglycaemia Study group
Diabetologia 2007

16. Morbidity of hypoglycaemia in type 2 DM
Different symptoms in elderly (eg mimic CVA)
Hypos can precipitate vascular events
T2DM pts need SAS at least as often as T1DM
Leese et al, Diabetes Care, 2003: 244 SH episodes in 160 people over 1yr in Tayside.
Emergency Rx needed for 7.1% of T1DM, 7.3% of insulin-treated T2DM and 0.8% of people on OHAs
Donnelly et al, Diabetic Medicine 2005: 267 people in Tayside with insulin-treated DM, FU for 1/12.
45% prevalence all hypo in insulin-treated T2DM
Only 10% of T1DM with SH needed emergency services vs 30% of T2DM
1. Leese GP, Wang J, Broomhall J, Kelly P, Marsden A, Morrison W, et al. Frequency of severe hypoglycemia requiring emergency treatment in Type 1 and Type 2 diabetes: a population-based study of health service resource use. Diabetes Care 2003;(1176):1180.
2. Donnelly LA, Morris AD, Frier BM, Ellis JD, Donnan PT, Durrant R, et al. Frequency and predictors of hypoglycaemia in type 1 and insulin-treated type 2 diabetes: a population based study. Diabetic Medicine 2005;22:

17. T2DM Old Age Hypoglycaemia Cognitive decline and dementia Frailty
Renal dysfunction
Increased mortality
Institutionalisatio
T2DM
Old Age
Hypoglycaemia
Decreased symptoms
Impaired counter regulation
Tight glycaemic control
Polypharmacy
Decreased microvascular complications.
No effect on macrovascular complications.
Mobility limitation and decline in physical function
Falls
Fractures

18. Guidelines on glycaemic targets in older pts

19. Guidelines on glycaemic targets in older pts

20. SGLT2 inhibitors: mode of action independent of beta cells
T2DM therapies
Targets insulin resistance
Targets insulin deficiency
Diet and lifestyle
Insulin secretagogues
Metformin
Insulin
Glitazones (TZDs)
DPP-IV inhibitors
GLP-1 analogues
SGLT2 inhibitors: mode of action independent of beta cells

21. T2DM therapies Pioglitazone: DPP-IV: GLP-1: SGLT2: No hypos
Wt gain, oedema, osteoporosis, ? Bladder cancer
DPP-IV:
No hypos, weight neutral
Not very potent. Reduce in renal impairment
GLP-1:
No hypos, weight loss
GI side effects, ? Pancreatitis, care in renal impairment, injections (but weekly formulation available)
SGLT2:
No hypos, weight loss, BP,  CV death (empagliflozin)
Need normal renal function. Not recommended in elderly

22. Guidelines on glycaemic targets in older pts
European Diabetes Working Party for Older People

23. Clinical guidelines elderly T2DM

24. Discussion