Glucose Control, Sulfonylureas, and Insulin Treatment in Elderly People With Type 2 Diabetes and Risk of Severe Hypoglycemia and Death: An Observational Study

Impacts of medication adherence and home healthcare on the associations between polypharmacy and the risk of severe hypoglycemia among elderly diabetic patients in Taiwan from 2002 to 2012: A nationwide case-crossover study

AIM

To assess how medication adherence and home healthcare support influence the role of polypharmacy in induced hypoglycemia events among elderly diabetic patients.

METHODS

This case-crossover study retrieved records on diabetic patients >=65 years with severe hypoglycemia from 2002 to 2012 in Taiwan. Case period defined as 1-3 days before severe hypoglycemia was compared with a preceding control period of the same length, with an all-washout period of 30 days. Moreover, the modifiable effects of medication adherence and home healthcare service use were evaluated by stratified analysis.

RESULTS

Totally 2,237 patients were identified. Polypharmacy use was associated with the risk of severe hypoglycemia. Patients receiving polypharmacy without home healthcare services (aOR: 1.34; 95 % CI: 1.16-1.54) and those with poor adherence to anti-diabetic medications (aOR: 1.48; 95 % CI: 1.24-1.77) were significantly associated with an elevated risk of severe hypoglycemia. In patients with good adherence, non-home healthcare users being prescribed with polypharmacy had a higher risk of severe hypoglycemia. In the group that received home healthcare services, patients with poor adherence using polypharmacy had a higher risk of severe hypoglycemia.

CONCLUSIONS

Good adherence and receiving home healthcare services were associated with a decreased odds of severe hypoglycemic events in elderly diabetic patients, regardless of the fact whether they were prescribed with polypharmacy.

Continuous Glucose Monitoring in Older Adults: What We Know and What We Have Yet to Learn

OBJECTIVE

To assess the growing use of continuous glucose monitoring (CGM) systems by older adults and explore additional areas integration that could benefit adults with frailty.

BACKGROUND

The use of CGM devices has expanded rapidly in the last decade. This has been supported by substantial data showing significant benefit in glycemic metrics: hemoglobin A1c improvements, less hypoglycemia, and improved quality of life. However, sub-populations, such as older persons, exist where available data are limited. Furthermore, frail older adults represent a heterogeneous population with their own unique challenges to the management of diabetes. This group has some of the poorest outcomes related to the sequela of diabetes. For example, hypoglycemia resulting in significant morbidity and mortality is more frequent in older person with diabetes than in younger persons with diabetes.

METHOD

We present a concise literature review on CGM use in the older adult as well as expand upon glycemic and nonglycemic benefits of CGM for patients, caregivers, and providers. Retrospective analysis of inpatient glycemic data of 16,935 older adults with Type 2 diabetes mellitus at Atrium Health Wake Forest Baptist indicated those with fraility managed with insulin or sulfonylurea had the highest rates of delirium (4.8%), hypoglycemia (3.5%), cardiovascular complications (20.2%) and ED visits/hospitalizatoins (49%). In addition, we address special consideration of specific situations including inpatient, palliative and long term care settings.

CONCLUSION

This review article summarizes the available data for CGM use in older adults, discusses the benefits and obstacles with CGM use in this population, and identifies areas of future research needed for improved delivery of care to older persons with diabetes.

Characteristics of elderly diabetes patients: focus on clinical manifestation, pathogenic mechanism, and the role of traditional Chinese medicine

Diabetes mellitus has become a major public health issue globally, putting an enormous burden on global health systems and people. Among all diseased groups, a considerable part of patients are elderly, while their clinical features, pathogenic processes, and medication regimens are different from patients of other ages. Despite the availability of multiple therapies and techniques, there are still numerous elderly diabetes patients suffering from poor blood glucose control, severe complications, and drug adverse effects, which negatively affect the quality of life in their golden years. Traditional Chinese Medicine (TCM) has been widely used in the treatment of diabetes for several decades, and its relevant clinical practice has confirmed that it has a satisfactory effect on alleviating clinical symptoms and mitigating the progression of complications. Chinese herbal medicine and its active components were used widely with obvious clinical advantages by multiple targets and signaling pathways. However, due to the particular features of elderly diabetes, few studies were conducted to explore Traditional Chinese Medicine intervention on elderly diabetic patients. This study reviews the research on clinical features, pathogenic processes, treatment principles, and TCM treatments, hoping to provide fresh perspectives on the prevention and management strategies for elderly diabetes.

Helical-Like Assembly of Nateglinide as Coating for Oral Delivery of Insulin and Their Synergistic Prevention of Diabetes Mellitus

Oral delivery of antidiabetic active components promises to free millions of people from daily suffering who require routine injections. However, oral insulin (Ins) and other short-acting compounds such as nateglinide (NG) in harsh gastrointestinal tract still face great challenging, including low bioavailability, and rapid elimination. In this study, inspired by the self-assembly of phenylalanine-based peptides in nature, it is showed that NG a small phenylalanine derivative, assembles into left-handed helical nanofibers in the presence of Ca2+ . These helical NG nanofibers functioned as a coating layer on the surface of Ca2+ -linked alginate (Alg) microgels for the effective encapsulation of Ins. As expected, the sustained release and prolonged circulation of Ins and NG from the Ins-loading Alg/NG microgels (Ins@Alg/NG) in the intestinal tract synergistically maintain a relatively normal blood glucose level in streptozotocin-induced diabetic mice after oral administration of Ins@Alg/NG. This further confirms that Ins@Alg/NG ameliorated Ins resistance mainly through activating Insreceptor substrate 1 (IRS1), protein kinase B (AKT), and AMP-activated protein kinase (AMPK), as well as by repressing glycogen synthase kinase-3β (GSK-3β). The strategy of using the assembly of NG as a coating achieves the oral delivery of insulin and showcases a potential for the treatment of diabetes.

Management of Type 2 Diabetes Mellitus in the Very Elderly: One Practice's Experience

OBJECTIVE

Type 2 diabetes mellitus (T2DM) affects 25% of adults over age 65. Nevertheless, few clinical trials include patients over age 75.

METHODS

This case series reports retrospective data on a cohort of 85 patients aged 80 and over (mean 88.1, range 80-104) with T2DM, managed by a single endocrinologist. The practice's computerized data base was searched for all patients 80 years of age and older with a diagnosis of T2DM.

RESULTS

The major observations were the significant decrease in the use of agents associated with hypoglycemia, (sulfonylureas and insulin), and the beneficial and well-tolerated use of glucagon like peptide-1 receptor analogues (GLP-1 RA). The mean A1c in the entire cohort dropped from 7.6% to 6.6% over a mean of 9 months. Nearly one-half of the cohort were treated with GLP1-RA, reflecting studies demonstrating the safety and efficacy of this class of drugs in less elderly patients. At presentation, 75% were on sulfonylurea and/or insulin; this number was reduced to 27%. Furthermore, none of the patients required short-acting (bolus) insulin to achieve the individualized A1c target.

CONCLUSION

Patients with T2DM aged 80 and over respond well to GLP1-RA drugs, drastically reducing the need for agents associated with hypoglycemia. The important question, which will require larger and prospective studies, is whether the lowering of A1c, as shown in this paper, and the use of GLP-1 RA specifically, are associated with improved morbidity and mortality in the very elderly.

A Qualitative Study of Perspectives of Older Adults on Deintensifying Diabetes Medications

BACKGROUND

While many older adults with type 2 diabetes have tight glycemic control beyond guideline-recommended targets, deintensifying (stopping or dose-reducing) diabetes medications rarely occurs.

OBJECTIVE

To explore the perspectives of older adults with type 2 diabetes around deintensifying diabetes medications.

DESIGN

This qualitative study used individual semi-structured interviews, which included three clinical scenarios where deintensification may be indicated.

PARTICIPANTS

Twenty-four adults aged ≥65 years with medication-treated type 2 diabetes and hemoglobin A1c <7.5% were included (to thematic saturation) using a maximal variation sampling strategy for diabetes treatment and physician specialty.

APPROACH

Interviews were independently coded by two investigators and analyzed using a grounded theory approach. We identified major themes and subthemes and coded responses to the clinical scenarios as positive (in favor of deintensification), negative, or ambiguous.

KEY RESULTS

Participants' mean age was 74 years, half were women, and 58% used a sulfonylurea or insulin. The first of four major themes was fear of losing control of diabetes, which participants weighed against the benefits of taking less medication (Theme 2). Few participants viewed glycemic control below target as a reason for deintensification and a majority would restart the medication if their home glucose increased. Some participants were anchored to their current diabetes treatment (Theme 3) driven by unrealistic views of medication benefits. A trusting patient-provider relationship (Theme 4) was a positive influence. In clinical scenarios, 8%, 4%, and 75% of participants viewed deintensification positively in the setting of poor health, limited life expectancy, and high hypoglycemia risk, respectively.

CONCLUSIONS

Optimizing deintensification requires patient education that describes both individualized glycemic targets and how they will change over the lifespan. Deintensification is an opportunity for shared decision-making, but providers must understand patients' beliefs about their medications and address misconceptions. Hypoglycemia prevention may be a helpful framing for discussing deintensification.

Clinical and Pharmacotherapeutic Profile of Patients with Type 2 Diabetes Mellitus Admitted to a Hospital Emergency Department

Type 2 diabetes mellitus (T2DM) is closely associated with other pathologies, which may require complex therapeutic approaches. We aim to characterize the clinical and pharmacological profile of T2DM patients admitted to an emergency department. Patients aged ≥65 years and who were already using at least one antidiabetic drug were included in this analysis. Blood glycemia, creatinine, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and hemoglobin were analyzed for each patient, as well as personal pathological history, diagnosis(s) at admission, and antidiabetic drugs used before. Outcome variables were analyzed using Pearson's Chi-Square, Fisher's exact test, and linear regression test. In total, 420 patients were randomly selected (48.6% male and 51.4% female). Patients with family support showed a lower incidence of high glycemia at admission (p = 0.016). Higher blood creatinine levels were associated with higher blood glycemia (p = 0.005), and hyperuricemia (HU) (p = 0.001), as well as HU, was associated with a higher incidence of acute cardiovascular diseases (ACD) (p = 0.007). Hemoglobin levels are lower with age (p = 0.0001), creatinine (p = 0.009), and female gender (p = 0.03). The lower the AST/ALT ratio, the higher the glycemia at admission (p < 0.0001). Obese patients with (p = 0.021) or without (p = 0.027) concomitant dyslipidemia had a higher incidence of ACD. Insulin (p = 0.003) and glucagon-like peptide-1 agonists (GLP1 RA) (p = 0.023) were associated with a higher incidence of decompensated heart failure, while sulfonylureas (p = 0.009), metformin-associated with dipeptidyl peptidase-4 inhibitors (DPP4i) (p = 0.029) or to a sulfonylurea (p = 0.003) with a lower incidence. Metformin, in monotherapy or associated with DPP4i, was associated with a lower incidence of acute kidney injury (p = 0.017) or acute chronic kidney injury (p = 0.014). SGLT2i monotherapy (p = 0.0003), associated with metformin (p = 0.026) or with DPP4i (p = 0.007), as well as insulin and sulfonylurea association (p = 0.026), were associated with hydroelectrolytic disorders, unlike GLP1 RA (p = 0.017), DPP4i associated with insulin (p = 0.034) or with a GLP1 RA (p = 0.003). Insulin was mainly used by autonomous and institutionalized patients (p = 0.0008), while metformin (p = 0.003) and GLP1 RA (p < 0.0001) were used by autonomous patients. Sulfonylureas were mostly used by male patients (p = 0.027), while SGLT2 (p = 0.0004) and GLP1 RA (p < 0.0001) were mostly used by patients within the age group 65-85 years. Sulfonylureas (p = 0.008), insulin associated with metformin (p = 0.040) or with a sulfonylurea (p = 0.048), as well as DPP4i and sulfonylurea association (p = 0.031), were associated with higher blood glycemia. T2DM patients are characterized by great heterogeneity from a clinical point of view presenting with several associated comorbidities, so the pharmacotherapeutic approach must consider all aspects that may affect disease progression.

Effect of Glucose Levels on Cardiovascular Risk

Cardiovascular diseases remain the leading cause of death and disability. The development of cardiovascular diseases is traditionally associated with various risk factors, most of which are somehow related to an unhealthy lifestyle (smoking, obesity, lack of physical activity, etc.). There are also risk factors associated with genetic predisposition, as well as the presence of concomitant diseases, especially chronic ones. One of the most striking examples is, of course, type 2 diabetes. This metabolic disorder is associated with impaired carbohydrate metabolism. The main clinical manifestation of type 2 diabetes is elevated blood glucose levels. The link between diabetes and CVD is well known, so it is logical to assume that elevated glucose levels may be important, to some extent, in the context of heart and vascular disease. In this review, we tried to summarize data on the possible role of blood glucose as a risk factor for the development of CVD.

Potential Risk of Overtreatment in Patients with Type 2 Diabetes Aged 75 Years or Older: Data from a Population Database in Catalonia, Spain

Aim: To assess the potential risk of overtreatment in patients with type 2 diabetes (T2DM) aged 75 years or older in primary care. Methods: Electronic health records retrieved from the SIDIAP database (Catalonia, Spain) in 2016. Variables: age, gender, body mass index, registered hypoglycemia, last HbA1c and glomerular filtration rates, and prescriptions for antidiabetic drugs. Potential overtreatment was defined as having HbA1c < 7% or HbA1c < 6.5% in older patients treated with insulin, sulfonylureas, or glinides. Results: From a total population of 138,374 T2DM patients aged 75 years or older, 123,515 had at least one HbA1c available. An HbA1c below 7.0% was present in 59.1% of patients, and below 6.5% in 37.7%. Overall, 23.0% of patients were treated with insulin, 17.8% with sulfonylureas, and 6.6% with glinides. Potential overtreatment (HbA1c < 7%) was suspected in 26.6% of patients treated with any high-risk drug, 47.8% with sulfonylureas, 43.5% with glinides, and 28.1% with insulin. Using the threshold of HbA1c < 6.5%, these figures were: 21.6%, 24.4%, 17.9%, and 12.3%, respectively. Conclusion: One in four older adults with T2DM treated with antidiabetic drugs associated with a high risk of hypoglycemia might be at risk of overtreatment. This risk is higher in those treated with sulfonylureas or glinides than with insulin.

Synthesis of Benzylidene Analogs of Oleanolic Acid as Potential α-Glucosidase and α-Amylase Inhibitors

A series of benzylidene analogs of oleanolic acid 4a∼4s were synthesized and assessed for their α-glucosidase and α-amylase inhibitory activities. The results presented that all synthesized analogs exhibited excellent-to-moderate inhibitory effects on α-glucosidase and α-amylase. Analog 4i showed the highest α-glucosidase inhibition (IC₅₀: 0.40 μM), and analog 4o presented the strongest α-amylase inhibition (IC₅₀: 9.59 μM). Inhibition kinetics results showed that analogs 4i and 4o were reversible and mixed-type inhibitors against α-glucosidase and α-amylase, respectively. Simulation docking results demonstrated the interaction between analogs and two enzymes. Moreover, analogs 4i and 4o showed a high level of safety against 3T3-L1 and HepG2 cells.

Intensive glycemic control and macrovascular, microvascular, hypoglycemia complications and mortality in older (age ≥60years) or frail adults with type 2 diabetes: a systematic review and meta-analysis from randomized controlled trial and observation studies

INTRODUCTION

Guidelines for type 2 diabetes (T2D) recommend individualized HbA1c targets to take into account patient age or frailty. We synthesized evidence from randomized controlled trials and observational studies for intensive glycemic control (HbA1c target ≤58 mmol/mol) versus standard care, in elderly (age ≥60 years) or frail adults with T2D.

METHODS

Searches were performed utilizing recognized terms for T2D, frailty, older age, and HbA1c control and outcomes of interest. Meta-analysis was performed where possible. Primary outcomes included all-cause mortality, severe hypoglycemia, and hospital admission rates. Vascular complications, cognitive decline, and falls/fractures were secondary outcomes.

RESULTS

7,528 studies were identified of which 15 different clinical studies were selected. No difference was noted in all-cause mortality with intensive control (pooled hazard ratio 0.96, 95% confidence interval 0.90-1.03), but risk of severe hypoglycemia increased (2.45, 2.22-2.72). Intensive control was associated reductions in microvascular (0.73, 0.68-0.79) and macrovascular complications (0.84, 0.79-0.89). Outcome data for risk of hospitalization, cognition, and falls/fractures were limited.

CONCLUSION

Intensive glycemic control was associated with reduced rates of complications but increased severe hypoglycemia. Significant heterogeneity exists and the impact of different drug regimens is unclear. Caution is needed when setting glycemic targets in elderly or frail individuals.

Using an Electronic Health Record and Deficit Accumulation to Pragmatically Identify Candidates for Optimal Prescribing in Patients With Type 2 Diabetes

OBJECTIVE

Despite guidelines recommending less stringent glycemic goals for older adults with type 2 diabetes, overtreatment is prevalent. Pragmatic approaches for prioritizing patients for optimal prescribing are lacking. We describe glycemic control and medication patterns for older adults with type 2 diabetes in a contemporary cohort, exploring variability by frailty status.

RESEARCH DESIGN AND METHODS

This was a cross-sectional observational study based on electronic health record (EHR) data, within an accountable care organization (ACO) affiliated with an academic medical center/health system. Participants were ACO-enrolled adults with type 2 diabetes who were ≥65 years of age as of 1 November 2020. Frailty status was determined by an automated EHR-based frailty index (eFI). Diabetes management was described by the most recent A1C in the past 2 years and use of higher-risk medications (insulin and/or sulfonylurea).

RESULTS

Among 16,973 older adults with type 2 diabetes (mean age 75.2 years, 9,154 women [53.9%], 77.8% White), 9,134 (53.8%) and 6,218 (36.6%) were classified as pre-frail (0.10 < eFI ≤0.21) or frail (eFI >0.21), respectively. The median A1C level was 6.7% (50 mmol/mol) with an interquartile range of 6.2-7.5%, and 74.1 and 38.3% of patients had an A1C <7.5% (58 mmol/mol) and <6.5% (48 mmol/mol), respectively. Frailty status was not associated with level of glycemic control (P = 0.08). A majority of frail patients had an A1C <7.5% (58 mmol/mol) (n = 4,544, 73.1%), and among these patients, 1,755 (38.6%) were taking insulin and/or a sulfonylurea.

CONCLUSION

Treatment with insulin and/or a sulfonylurea to an A1C levels <7.5% is common in frail older adults. Tools such as the eFI may offer a scalable approach to targeting optimal prescribing interventions.

A Review on the Structure and Anti-Diabetic (Type 2) Functions of β-Glucans

Type 2 diabetes, a long-term chronic metabolic disease, causes severe and increasing economic and health problems globally. There is growing evidence that β-glucans can function as bioactive macromolecules that help control type 2 diabetes with minimal side effects. However, conflicting conclusions about the antidiabetic activities of β-glucans have been published, potentially resulting from incomplete understanding of their precise structural characteristics. This review aims to increase clarity on the structure-function relationships of β-glucans in treating type 2 diabetes by examining detailed structural and conformational features of naturally derived β-glucans, as well as both chemical and instrumental methods used in their characterization, and their underlying anti-diabetic mechanisms. This may help to uncover additional structure and function relationships and to expand applications of β-glucans.