Diabetes Flashcards
For the older person with diabetes and multiple comorbidities and/or frailty, what is the key principle guiding choice of antihyperglycemic therapy and A1c target?
Strictly prevent hypoglycemia
What are reasons not to start somebody on SGLT-2 inhibitor?
- Complex comorbidities - inc risk of AEs
- Most studies done on <70 without comorbidities so outcomes unclear
- Inc risk with low GFR
- More susceptible to dehydration, fractures
How should the targets of functionally independent older adults with diabetes with greater than 10 year life expectancy, compare with younger patients with diabetes with regard to BP targets?
They are the same
What diabetes medications should be stopped in older adults?
Sulfonylureas = inc risk of hypoglycemia
Gliclazide, glyburide
What is the first line agent for diabetes in older adults?
Metformin
What are second line options for oral diabetic agents?
GLP-1 receptor agonists ex. semaglutide
SGLT2 inhibitors ex. canagliflozin
What factors influence A1c target ranges?
Frailty
Functional dependence
Dementia
End of life
What are the A1c targets for patients based on CFS?
CFS 1-3
- A1c <= 7
- Pre 4-7
- Post 5-10
CFS 4-5
- A1c <8 / 7.1-8%
- Pre 5-8
- Post <12
CFS 6-8/Frail/Dementia
- A1c <8.5 / 7.1-8.5%
- Pre 6-9
- Post <14
End of Life/CFS 9
Don’t measure A1c
Avoid symptomatic hyperglycemia
Avoid any hypoglycemia
What are the main deficits with respect to diabetes for a lean older adult and overweight older adult?
Lean: impaired glucose induced insulin secretion
Overweight: resistance to insulin-mediated glucose disposal, with insulin secretion being relatively preserved
What is the target LDL for diabetics?
<2 or >50% reduction from baseline
What A1c levels are associated with increased risk of fracture?
<6.5% and >8%
What is the pathogenesis of glucose intolerance in the elderly?
Aging = inc insulin resistance = cells less able to dispose of glucose = inc blood glucose
Aging = islet cell dysfunction = dec production of insulin
What is the target BP in older adults with diabetes?
<130/80
What systolic BP should you not go below in diabetic?
Independent don’t go SBP <120
Dependent don’t go SBP <130
<130/<67 may inc mortality rate
What are 6 barriers to diabetes management that those with IC might have?
- Forgetting to take their medications or taking them improperly
- Difficulties following dietary recommendations
- Difficulties remembering to check blood sugar or not knowing how
- Not recognizing symptoms of hypoglycemia or hyperglycemia
- Not remembering how to manage hypo or hyperglycemia
- May not be able to follow sick day recommendations
- Infrequent meals, variable quality and quantity
What is one pharmacodynamic drug interaction of glyburide that can cause hypoglycemia?
More sensitive to hypoglycaemic effects of glyburide (sulfonylurea) in aging
What is the drug interaction between TMP-SMX and glyburide?
SMX is a weak CYP2C9 inhibitor which metabolizes glyburide
There is also plasma protein binding competition which inc levels of glyburide
List 5 reasons for permissive hyperglycemia in elderly in LTC
- High prevalence of frailty and dementia
- A1c <6% higher rates of mortality
- A1c <6.5% higher rates of fracture
- Risks of hypoglycemia like falls, seizure, CV event
- Inc risk of asymptomatic hypoglycemia
What A1c is associated with higher mortality?
<6%
What are 3 factors predisposing the elderly to hypoglycemia?
Age related reduction in glucagon secretion
Impaired awareness of hypoglycemia symptoms
Altered psychomotor - less able to treat hypoglycemia
What are the main categories of diabetes medications?
Biguanide (Metformin)
DPP-4 Inhibitors (gliptins)
GLP-1 R agonists (liraglutide)
SGLT-2 inh (empagliflozin)
Alpha glucosidase inh (acarbose)
Insulin secretagogues (meglitinides, sulfonylurea)
Thiazolidinediones (rosiglitazone)
Metformin: MOA, benefits, risks
MOA = biguanide, enhance insulin sensitivity in liver and tissues
Benefits = low cost, weight neutral, reduce MI, low risk hypoglycemia
Risks = N/V/D, B12 deficiency, CI GFR <30
DPP-4 inhibitors: MOA, benefits, risks
Sitagliptin, linagliptin
MOA: incretin, inc glucose dependent insulin release
Benefits: weight neutral, low risk hypoglycemia
Risks: pancreatitis, sev joint pain
GLP-1 receptor agonists: MOA, benefits, risks
Liraglutide, semaglutide
MOA: incretin, inc glucose dependent insulin release
Benefits: weight loss (slow digestion, reduce appetite), low risk hypoglycemia, reduction in MACE and CV death, reduced progression of nephropathy
Risks: N/V/D, gallstone, CI if hx thyroid cancer or MEN-2, monitor retinopathy
SGLT-2 inhibitors: MOA, benefit, risk
Empagliflozin
MOA: reduce glucose by reabsorption in the kidney
Benefit: weight loss, low risk hypoglycemia, reduction MACE/CV death, reduced progression of nephropathy, reduced CHF
Risks: euglycemic DKA, genital mycotic infections, UTIs, inc urination, HOTN, AKI, CI if GFR<45 (Cana, empa) or <60 (dapa)
Insulin secretagogues: MOA, benefit, risk
Sulfonylureas, meglitinides
MOA: activates sulfonylurea receptor on beta islet cell to stimulate insulin secretion
Benefits: low cost
Risks: weight gain, hypoglycemia, not durable glycemic control
Thiazolidinediones: MOA, benefit, risks
MOA: enhance peripheral and hepatic insulin sensitivity
Benefits: durable glycemic control
Risks: weight gain, edema, CHF, cost, fractures, inc risk MI with rosi
Alpha glucosidase inhibitor: MOA, benefits, risks
MOA: inhibit pancreatic alpha amylase and intestinal alpha glucosidase
Benefit: weight neutral, mod cost
Risk: GI sfx, TID dosing
What are 3 interventions to reduce hypoglycemia risk?
- Stop agents that can cause hypoglycemia
- Educate patient and caregiver on risk of hypoglycemia
- Set glycemic targets taking into account frailty
