Evidence-informed guidelines for treating frail older adults with type 2 diabetes: from the Diabetes Care Program of Nova Scotia (DCPNS) and the Palliative and Therapeutic Harmonization (PATH) program

Abstract

Clinical practice guidelines specific to the medical care of frail older adults have yet to be widely disseminated. Because of the complex conditions associated with frailty, guidelines for frail older patients should be based on careful consideration of the characteristics of this population, balanced against the benefits and harms associated with treatment. In response to this need, the Diabetes Care Program of Nova Scotia (DCPNS) collaborated with the Palliative and Therapeutic Harmonization (PATH) program to develop and disseminate guidelines for the treatment of frail older adults with type 2 diabetes. The DCPNS/PATH guidelines are unique in that they recommend the following: 1. Maintain HbA1c at or above 8% rather than below a specific level, in keeping with the conclusion that lower HbA1c levels are associated with increased hypoglycemic events without accruing meaningful benefit for frail older adults with type 2 diabetes. The guideline supports a wide range of acceptable HbA1c targets so that treatment decisions can focus on whether to aim for HbA1c levels between 8% and 9% or within a higher range (ie, >9% and <12%) based on individual circumstances and symptoms. 2. Simplify treatment by administering basal insulin alone and avoiding administration of regular and rapid-acting insulin when feasible. This recommendation takes into account the variations in oral intake that are commonly associated with frailty. 3. Use neutral protamine Hagedorn (NPH) insulin instead of long-acting insulin analogues, such as insulin glargine (Lantus) or insulin detemir (Levemir), as insulin analogues do not appear to provide clinically meaningful benefit but are significantly more costly. 4. With acceptance of more liberalized blood glucose targets, there is no need for routine blood glucose testing when oral hypoglycemic medications or well-established doses of basal insulin (used alone) are not routinely changed as a result of blood glucose testing.Although these recommendations may appear radical, they are based on careful review of research findings.

Keywords: Clinical practice guidelines; diabetes; frailty; glycosylated hemoglobin (HbA1c); random blood glucose.