Suitable Use of Injectable Agents to Overcome Hypoglycemia Risk, Barriers, and Clinical Inertia in Community-Dwelling Older Adults with Type 2 Diabetes Mellitus

Abstract

The management of type 2 diabetes mellitus in older adults requires a comprehensive understanding of the relationship between the disease (medical) and the functional, psychological/cognitive, and social geriatric domains, to individualize both glycemic targets and therapeutic approaches. Prevention of hypoglycemia is a major priority that should be addressed as soon as its presence or risk is detected, adjusting the target and therapeutics accordingly. Nonetheless, treatment intensification should not be neglected when applicable, consistent with recommendations from organizations such as the American Geriatrics Society and the American Diabetes Association, to reduce not only long-term macrovascular and microvascular complications (individualization), but also short-term complications from hyperglycemia (polyuria, volume depletion, urinary incontinence). Such complications can negatively impact the physical and cognitive function of older adults, worsen their quality of life, and additionally affect their families and society. We emphasize individualization, utilizing the multiple classes of antihyperglycemic agents available. Metformin remains as first-line therapy, and additional agents offer advantages and disadvantages that ought to be considered when developing a patient-centric plan of care. For selected cases, injectable therapies such as long-acting basal insulin analogs and glucagon-like peptide-1 receptor agonists can offer advantages to counter hypoglycemia risk, patient-related barriers, and clinical inertia. Furthermore, some injectable agents could potentially simplify regimens while providing safe and effective glycemic control. In this review, we discuss the use of injectable therapies for selected community-dwelling older adults, barriers to transition to injectable therapy, and measures aimed at removing these barriers and assisting physicians and their teams to transition older patients to injectable therapies when appropriate.

Fig. 1

A comprehensive approach to diabetes management in older adults. Evaluation and understanding of the four geriatric domains are fundamental for the implementation of best practices in older adults with diabetes. The four domains are intertwined, with interactions that impact diabetes self-management and self-efficacy, adherence, and risks. A healthy older adult can receive aggressive interventions in the setting of excellent self-management and self-efficacy skills and access to care and social support. As the person ages, not only does T2D run its natural course of progressive disease, but pharmacologic management becomes more challenging because of multimorbidity, functional impairment, and cognitive decline, among others, which limit self-management and self-efficacy. Diabetes targets need to be reviewed and adjusted accordingly. Avoiding hypoglycemia is the priority, while preserving quality of life is a major outcome and marker of successful management. As life expectancy decreases, therapy will focus on the prevention of hyperglycemia emergencies, diabetic polyuria, and dehydration. T2D type 2 diabetes. Adapted from Valencia and Florez [1]