Diabetes and aging Robert Lash, M.D. Old news: theres a diabetes - - PowerPoint PPT Presentation

Diabetes and aging

Robert Lash, M.D.

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

5 10 15 20 25 1 2 3 4 5 6 7 8 1958 61 64 67 70 73 76 79 82 85 88 91 94 97 00 03 06 09 11

Number with Diabetes (Millions) Percentage with Diabetes

Year

Percentage with Diabetes Number with Diabetes

Old news: there’s a diabetes epidemic

85% 85% of

• f pa

patien tients ts ar are di diagnosed agnosed af after ter the they turn turn 40 40

http://www.cdc.gov/diabetes/statistics/age/fig1.htm

AGING, March 2014, Vol. 6 No.3

Wh Why is is diabe diabetes es mor more co common mmon as as we we ag age? e?

The The re result – a – a lot lot of

• f older
• lder Am

Americ ericans ans ha have diabe diabetes es

5 10 15 20 25 30 20 ‐ 44 45 ‐ 64 65 or older Percentage of patients with diabetes

Ar Areas eas of

• f co

concern fo for ol

• lder

der pa patien tients ts

• Glucose control targets
• Treatment choices (and avoiding hypoglycemia)
• Treating cholesterol and hypertension
• Complication screening
• Foot care

Gl Glycemi emic co cont ntrol co considerat ations

Good functional status Life expectancy > 10 years Short duration of diabetes Minimal comorbidities Hypoglycemia Shorter life expectancy Comorbidities/disabilities Fall risk/functional impairment Polypharmacy A1c < 7.5% Fasting glucose 140‐150 mg/dL A1c < 8.5% Average glucose ~200 mg/dL A1c < 8.0% Fasting glucose 160‐170 mg/dL

Trea eatm tmen ent choices choices (and (and av avoiding hy hypoglycemia)

Pre‐1995

• Insulin
• Sulfonylureas

Post‐1995

• Metformin
• Disaccharidase inhibitors
• GLP‐1 agonists
• DPP‐IV inhibitors
• SGLT2 inhibitors
• (Bromocriptine)

Trea eatm tmen ent choices choices (and (and av avoiding hy hypoglycemia)

Weight gain

• Insulin
• Sulfonylureas

Weight loss or neutral

• Metformin
• Disaccharidase inhibitors
• GLP‐1 agonists
• DPP‐IV inhibitors
• SGLT2 inhibitors
• (Bromocriptine)

Trea eatm tmen ent choices choices (and (and av avoiding hy hypoglycemia)

Risk of hypoglycemia

• Insulin
• Sulfonylureas

No hypoglycemia

• Metformin
• Disaccharidase inhibitors
• GLP‐1 agonists
• DPP‐IV inhibitors
• SGLT2 inhibitors
• (Bromocriptine)

Emergency Hospitalizations for Adverse Drug Events in Older Americans

Budnitz DS, et. al.

• NEJM. 365:2002‐12. (2011)

Budnitz DS, et. al. NEJM. 365:2002‐12. (2011)

Hypoglycemia is a frequent cause of drug‐related emergency hospitalizations

A Systematic Review and Meta-Analysis of Hypoglycemia and Cardiovascular Events

A comparison of glyburide with other secretagogues and with insulin

Ganji AS, Cukierman T, Gerstein HC, et. al. Diabetes Care 30:389–394 (2007)

Comparator Any hypoglycemia All hypoglycemia (per patient- year) Major hypoglycemia (per patient- year) CV events Death Sulfonylureas 1.83 (1.35-2.49) 1.44 (1.13-1.85) 4.7 (0.78-28.1) 0.92 (0.71- 1.19) 0.79 (0.47-1.32) Insulin 0.88 (0.25- 3.06) 0.09 (0.02-0.41) ND 0.89 (0.7-1.14) 0.97 (0.79-1.20)

Glyburide causes more hypoglycemia than other sulfonylureas

Ganji AS, et. al. Diabetes Care 30:389–394 (2007)

Tr Treating choles cholesterol and and hy hypertension

• Cholesterol
• Statins remain a good idea
• Reduce risk of CV events in patients with diabetes, regardless of starting LDL
• This year’s controversy: should there (once again) be LDL targets?
• Hypertension
• Hypertension is more common as we age
• Most ‘bang for the buck’ in reducing CV risk
• This year’s controversy: what treatment goal should we pick?

Compl Complicati tion

• n scr

screening eening

• Eye exams
• Should still be yearly for most patients
• Glaucoma and cataracts are more common in patients with diabetes
• Screening for kidney involvement
• Yearly, unless patient is already on an ACE or an ARB
• Coronary artery disease
• Check LDL
• Ask about anginal symptoms, and listen carefully
• It’s never too late to stop smoking

• Diabetes is the number one cause of non‐

traumatic foot amputations

• 50% of older patients with diabetes have

neuropathy

• 30% of older patients with diabetes can’t see
• r reach their feet
• Feet should be examined at every visit, and

home foot care reviewed

• Low threshold for referral to podiatry

Things Things to to re reme memb mber if if yo you’re re jus just wa waking up up

• One‐quarter of older Americans have diabetes
• Their treatment targets depend on their health and life expectancies
• Try to avoid hypoglycemia
• Don’t forget about treating hypertension and cholesterol
• Complication screening is still important
• Foot care is often overlooked. . . and shouldn’t be