Drug therapy of diabetes in the elderly

The effect of saffron supplementation on glycemic parameters: An overview of systematic reviews

Due to the widespread use of herbal medicine and evidence pointing to the health benefits of saffron supplementation, this review was performed to evaluate the effects of saffron supplementation on glycemic parameters and lipid profiles based on previous reviews. Relevant articles were retrieved from various databases, which included PubMed, Scopus, ProQuest, Web of Science, Embase, and Cochrane until 2020, with no date restrictions. The quality of the included reviews was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) checklist. Finally, of 877 obtained articles, eight reviews meeting the inclusion criteria were included for analysis. Among the eight included reviews, seven articles were meta-analyses. In addition, one review had an average quality while seven had a good quality. A narrative description of the included reviews was performed, while a network meta-analysis was not conducted. A brief review of the results was reported according to the weighted mean difference and mean difference. Seven included reviews assessed the effects of saffron or crocin supplementation on glycemic parameters, and six examined these effects on lipid profile parameters. Almost half of the articles reported significant effects of these supplements on glycemic parameters and lipid profiles. Taken together, results suggest that saffron supplementation may improve glycemic and lipid profile parameters; however, further high-quality studies are needed to confirm the clinical efficacy of saffron on glycemic parameters and lipid profiles.

A retrospective cross-sectional study of type 2 diabetes overtreatment in patients admitted to the geriatric ward

Background

Glycemic control targets in older patients should be individualized according to functional status and comorbidities. The aim of the study was to identify high-risk patients who had evidence of tight glycemic control and thus at risk of serious hypoglycemia.

Methods

Retrospective cross-sectional study of type 2 diabetes patients admitted to the geriatric ward receiving diabetes medications. Patients’ hospital records were analyzed. The high risk of hypoglycemia group constituted patients who were aged 80+ years, diagnosed with dementia, with end- stage renal disease, or with a history of macrovascular complications. The primary outcome measure was hemoglobin A_1C (HbA_1C) ≤ 7.0% [53 mmol/mol].

Results

Two hundred thirteen patients were included (77.5% women; 49.3% 80+ year-old). 65.3% received sulfonylurea, 39,4%- metformin, 32.9%- insulin, and 4.2%- acarbose (in 61.5% as monotherapy, and in 38.5% combination therapy). We identified 130 patients (60%) as the denominator for the primary outcome measure; 73.1% had a HbA_1C value ≤7.0% [53.3 mmol/mol], but 55.4% ≤6,5% [48.8 mmol/mol], and 40.8% ≤6.0% [42 mmol/mol].

Conclusions

The results show a very high rate of tight glycemic control in older patients admitted to the geriatric ward, for whom higher HbA_1C targets are recommended. This indicates the high probability of diabetes overtreatment in this group, associated with a high risk of recurrent hypoglycemia. This is all the more likely because most of them received medications known to cause hypoglycemia. This points to the need of paying more attention to specific difficulties in diabetes treatment in older people, especially those suffering from various geriatric syndromes and diseases worsening their prognosis.

Evidence-Based Management of Diabetes in Older Adults

The number of older adults with diabetes is rapidly increasing worldwide. A variety of factors contribute to the age-related increase in the incidence of diabetes. The lack of empiric evidence in the field has limited the management guidelines to mostly expert opinion. Given uncertainty over the rate at which to lower blood glucose levels and the optimal method of doing so, the goals of diabetes control in older people must be individualized. If the patient requires insulin therapy, the newer insulins, with their improved pharmacodynamic consistency and reduced risk of hypoglycemia, should be preferred. Several oral agents are preferable for people with sufficient endogenous insulin because they do not cause hypoglycemia when used as monotherapy. Some of these oral agents have been found to have cardioprotective effects. Older people with diabetes also require management of the other risk factors for cardiovascular disease, with antihypertensive drugs, cholesterol-lowering agents and low-dose aspirin. However, the precise targets for blood pressure control and low-density lipoprotein (LDL) cholesterol levels continue to evolve as more data become available. Diabetes care in older adults should focus on enhancing the individual's quality of life rather than trying to normalize blood glucose levels or reach predetermined blood pressure and LDL cholesterol targets.

Effects of hospital generic drug substitution on diabetes therapy

OBJECTIVES

To evaluate the effects on physicians' prescribing behavior and on the therapeutic outcome of non-insulin-dependent diabetes patients of substituting different generic brands of metformin.

METHODS

We adopt a retrospective cohort study involving 280 type-2 diabetes patients who regularly used the outpatient services of one medical center and who had changed metformin brands five times between 2003 and 2008. The aim was to examine the effects of switching brands. The generalized estimating equation was used to determine whether drug brand switching affected patient glycated hemoglobin A1c (HbA1c) levels, their prescribed daily dose, or their adherence to medication with metformin.

RESULTS

HbA1c levels increased from 7.91 to 8.34 throughout the study period, although it was found that brand switching did not adversely affect HbA1c levels after controlling for patient characteristics and the time course of the study. Furthermore, the prescribed daily dose of metformin was stable throughout the study period, and was approximately 0.8 of the defined daily dose. Finally, although adherence was significantly higher with the original metformin than with the four generic brands, patients still maintained high levels of adherence of >0.8.

CONCLUSION

Although switching between different brands of metformin slightly affected the prescribing behavior of the physicians, there was no unfavorable effect on patient HbA1c levels. Thus, the policy of substituting between different generic brands of metformin is a good cost-effective approach that does not adversely affect the quality of diabetes patient care.

A comparison on insulin regimen treatment of elderly (>70 years) and younger (<70 years) type 2 diabetic patients in actual clinical practice

The incidence of type 2 diabetes mellitus increases with age. However, there are few data about the most adequate type of insulin, or the most adequate insulin regimen, for elderly patients with diabetes. The present study compared insulin regimens in patients aged more than 70 years (100 subjects) with those aged less than 70 years (73 subjects) who attended a diabetes outpatient clinic. The weight, body mass index, diabetes-associated chronic complications, other cardiovascular risk factors, type of insulin, insulin regimen, total daily dose of insulin, weight-adjusted total daily dose of insulin, concomitant treatment with oral hypoglycaemic agents (OHA) and glycosylated haemoglobin (HbA1c) were compared between the two groups. Although both groups had the same level of metabolic control (HbA1c: 7.66 ± 0.91 in the elderly group vs. 7.62 ± 0.96 in the younger group), we have found that elderly subjects were more likely to be treated with a simple regimen, as shown by a higher use of basal insulin (15% in young patients and 41% in the elderly group; P < 0.001), lower use of fast-acting insulin (32.8% vs. 15%; P = 0.005), and fewer daily injections (45% vs. 22% received at least three injections each day; P = 0.001). There were no differences in the use of OHA; however, the majority of young patients were treated with metformin, whereas repaglinide was most commonly used in the elderly group. In conclusion, in everyday clinical practice, elderly subjects were treated with the simplest regimen and achieved the same level of metabolic control as young diabetic patients.

Special considerations with insulin therapy in older adults with diabetes mellitus

Aging is associated with alterations in insulin secretion and action. However, aging per se does not alter the pharmacokinetics of commercially available insulin and its analogues. Insulin therapy in older adults is complicated by psychosocial and physiological changes of aging. Several new insulin and insulin analogue preparations are now available for clinical use. Used as prandial (e.g. insulin lispro, insulin aspart or insulin glulisine) and basal insulin (e.g. insulin glargine, insulin detemir), these analogues simulate physiological insulin profiles more closely than the older conventional insulins. The availability of multiple insulin products provides new opportunities to achieve control of diabetes mellitus. The choice of initial insulin therapy can be made based on blood glucose profiles. Overall, these profiles can be divided into three general patterns that include: (i) round-the-clock hyperglycaemia; (ii) fasting hyperglycaemia with daytime euglycaemia; and (iii) daytime hyperglycaemia with normal fasting blood glucose levels. The prescription of insulin is a dynamic process, and the insulin regimen should be adjusted based on individual response. The goal of diabetes care in older adults is to enhance quality of life without subjecting individuals to complicated treatment regimens that may interfere with their independence in carrying out daily activities.

Pharmacoeconomics and aging

The aging of the general population in industrialized countries has brought to public attention the increasing incidence of age-related clinical conditions, because the long-term impact of diseases on functional status and on costs are greater in older people than in any other age group. With the aging of the population, it is becoming increasingly important to quantify the burden of illness in the elderly; this will be vital not only in planning for the necessary health services that will be required in coming years, but also in order to measure the benefit to be expected from interventions to prevent disability in older people. The management of multiple and chronic disorders has become a more important issue for healthcare authorities because of increasing requests for medical assistance and healthcare interventions. Among these, pharmacological treatments and drug utilization in older people are pressing issues for healthcare managers and politicians; indeed, a relatively small proportion of the population accounts for a substantial part of public drug costs. Two key sources of pressure are well known: the growing number of elderly persons, who are the highest per-capita users of medicines, and the introduction of new, often more expensive, medicines. On the other hand, the development of strategies for controlling costs, while providing the elderly with equitable access to needed pharmaceuticals, should be based on an evaluation of the economic impact of pharmacological care in older people, taking into account the burden of illness, drug utilization data, drug technology assessment evidence and results. Furthermore, there are major factors affecting pharmacological care in older people: for example inappropriate prescribing, lack of adherence and compliance, and the burden of adverse drug events. The assessment of these factors should be considered a priority in pharmacoeconomic evaluations in the aging population, and the most relevant evidence will be reviewed in this paper with examples referring to particular settings or conditions and diseases, such as the presence of cardiovascular risk factors, diabetes and chronic pain.

Nutritional considerations for older adults with type 2 diabetes

As Western populations age, the burden of associated chronic diseases, including diabetes, cardiovascular disease (CVD), and cancer will increase dramatically. In the United States in the next 50 years, it is projected that the percentage of adults with type 2 diabetes will exceed 30%, with the vast majority older than 65 years. It is therefore important to determine the best possible dietary and lifestyle modifications to prevent and control this disease and its associated complications. Although few data are available regarding the optimal nutritional regimen for the elderly with type 2 diabetes, as a general rule, the use of nutrient-dense, low glycemic index, high-dietary fiber foods with possibly higher protein intake is recommended.

Gastric emptying, diabetes, and aging

Gastric emptying is mildly slowed in healthy aging, although generally remains within the normal range for young people. The significance of this is unclear, but may potentially influence the absorption of certain drugs, especially when a rapid effect is desired. Type 2 diabetes is common in the elderly, but there is little data regarding its natural history, prognosis, and management. This article focuses on the interactions between gastric emptying and diabetes, how each is influenced by the process of aging, and the implications for patient management.

Cytoprotection of PEG-modified adult porcine pancreatic islets for improved xenotransplantation

Functional poly(ethylene glycol) (PEG) derivatives, including monosuccinimidyl PEG (MSPEG) with molecular weight (MW) of 2000 (2 kDa) as well as 5 kDa and disuccinimidyl PEG (DSPEG) with MW of 3 and 6 kDa, were synthesized and characterized. They were used to modify the surface of adult porcine islets for cytoprotection. The islets were isolated, purified and modified with functional PEG. Untreated porcine islets were used as control. An in vitro human antibody/complement-mediated cytotoxicity test based on the release of intracellular lactate dehydrogenase was used to evaluate cytotoxicity of human serum to the modified islets. In vitro cell viability was assessed using membrane-integrity straining and islet metabolism in culture. In vitro islet functionality was evaluated by glucose-stimulated insulin release of islets in static incubation with human serum. In vivo islet functionality was evaluated by monitoring non-fasting blood glucose level in streptozotocin-induced diabetic (SCID) immunocompromized mice after intraportal transplantation of porcine islets. Results show that all the PEG derivatives used in the study showed significant in vitro and in vivo cytoprotections against cytotoxic effects elicited by human serum and diabetic SCID mice, respectively, to porcine islets. DSPEG derivatives combined with human albumin exhibited a better cytoprotection, as compared to MSPEG ones, due to the capacity of the succinimidyl groups to selectively react with amino groups of the albumin under physiological conditions. The effects of both MW and concentration of the PEG derivatives on cytoprotection were significant. It appears that this novel biotechnology will be an attractive approach for improved xenotransplantation of islets.

Management of Diabetes Mellitus Medications in the Nursing Home

Nursing home staff are well aware of the increasing number of residents who experience diabetes mellitus. These residents consume an inordinate amount of resources and often have major disabilities and co-morbidities. Although nonpharmacological therapies, such as consistent carbohydrate intake and increased activity levels, are always indicated in diabetes management, pharmacological therapies are often necessary to prevent the acute complications of diabetes and delay some of the long-term complications. Residents with type 2 diabetes may be managed with oral antidiabetic agents and insulin, whereas residents with type 1 diabetes will always require insulin. Oral antidiabetic agents include insulin secretagogues, which stimulate endogenous insulin secretion and are most effective in leaner persons with type 2 diabetes. Metformin is another oral antidiabetic agent; this decreases inappropriate hepatic glucose release and is most effective in obese residents with high fasting blood glucose levels. The thiazolidinediones, also called glitazones, are insulin sensitisers that enable peripheral tissues to utilise insulin more effectively. The alpha-glucosidase inhibitors delay intestinal absorption of ingested carbohydrates. In addition to oral antidiabetic agents, insulin is frequently used in diabetes management. Insulin is always indicated in type 1 diabetes and is often necessary for residents with type 2 diabetes to optimise glycaemic control. Insulin can be rapid, fast, intermediate or long acting. In addition, basal insulin is now available. These insulins can be combined with each other and, in type 2 diabetes, with oral antidiabetic agents. In order to use pharmacological therapies appropriately, the glycaemic patterns of nursing home residents should be identified, using capillary blood glucose monitoring. Once these patterns have been identified, nonpharmacological therapies can be used, usually in conjunction with the many oral antidiabetic agents and various insulins available, to optimise glycaemic control in each resident.

Pioglitazone is Effective Therapy for Elderly Patients with Type 2 Diabetes Mellitus

BACKGROUND

Pioglitazone as monotherapy and in combination with sulfonylurea, metformin, or insulin has consistently demonstrated improved glycaemic and lipid parameters in patients with type 2 diabetes mellitus.

OBJECTIVE

We performed a subanalysis to examine the effect of pioglitazone on glycaemia and lipids in patients <65 and > or =65 years of age in two double-blind, placebo-controlled monotherapy studies and in three separate multi-centre trials.

METHOD

In Study 1, 197 patients were randomised to receive pioglitazone 30 mg/day or placebo for 16 weeks. Study 2 was a forced dose-titration trial in patients randomised to receive pioglitazone 7.5/15/30 mg/day, pioglitazone 15/30/45 mg/day, or placebo daily for 26 weeks. Each of the lower dosages was given for at least 4 weeks and the highest dosage for 16 weeks. The three combination studies evaluated efficacy of pioglitazone 30 or 45 mg/day over a 24-week period in combination with sulfonylureas, metformin, or insulin.

RESULTS

In both placebo-controlled monotherapy studies, at 16 weeks, and at maximum pioglitazone dosage, 0.53-0.55% and 0.57-1.27% mean reductions from baseline in glycosylated haemoglobin (HbA(1c)) were seen in patients aged <65 (n = 225) and > or =65 (n = 45) years, respectively. There were statistically significant differences between the placebo and pioglitazone groups in each age cohort. Similar effects were observed in fasting plasma glucose (FPG) levels, with 2.03-2.59 mmol/L and 3.20-4.44 mmol/L mean reductions from baseline, respectively, which were significantly different from the changes in the placebo group, but there was no difference between pioglitazone groups. At treatment endpoint in combination trials, pioglitazone added to sulfonylurea produced a mean decrease in HbA(1c) of 0.78-1.61%, and 1.64-1.96% in patients aged <65 (n = 557) and > or =65 (n = 115) years, respectively. Pioglitazone added to metformin produced a mean decrease in HbA(1c) of 0.78-1.03% and 0.78-0.98% in patients aged <65 (n = 686) and > or =65 (n = 112) years, respectively. Pioglitazone added to insulin produced a mean decrease in HbA(1c) of 1.13-1.37% and 1.39-1.66% in patients aged <65 (n = 500) and > or =65 (n = 156) years, respectively. In patients aged > or =65 years, hypoglycaemia was observed in 1 of 14 patients and in 0 of 13 patients in the two monotherapy studies. In the combination studies, the incidence of hypoglycaemia among patients aged > or =65 years was as follows: 26.7-28.8% combined with sulfonylurea; 0-4.4% combined with metformin; and 53.4-56.4% combined with insulin.

CONCLUSION

Pioglitazone monotherapy, or added to a sulfonylurea, metformin, or insulin demonstrated no significant differences in effectiveness while exhibiting similar adverse events in patients aged > or =65 years compared with patients aged <65 years. Well-controlled randomised clinical trials are recommended to confirm the impact of pioglitazone therapy on the glycaemic and lipid control in elderly patients with type 2 diabetes.