Derek LeRoith, MD, on the Endocrine Society’s Guideline for Treating Diabetes in Older Adults
In March 2019, the Endocrine Society published a clinical practice guideline for the treatment of diabetes in older adults.
Endocrinology Consultant discussed the new guideline further with Derek LeRoith, MD, PhD, professor of medicine in the division of Endocrinology, Diabetes and Bone Diseases at Icahn School of Medicine at Mount Sinai in New York, and a member of the task force that developed the guideline.
Endocrinology Consultant: Why was it important to develop this guideline for the treatment of diabetes in older adults, especially as treatment has become increasingly individualized?
Dr LeRoith: For several decades, many physicians treating patients with diabetes had viewed older adults with diabetes (ie, those aged 65 years or older), as having a limited life expectancy. However, over the last decade, the medical community has come to realize that there are many patients with diabetes aged 65 years, 75 years, 85 years, and even older that need proper treatment. Developing guidelines on how to treat this patient population in particular was important, because in the past these patients had often been ignored, thus allowing their diabetes to get out of control and lead to complications. Of course, there are differences between older patients and younger patients with diabetes, so it was important to have guidelines that allowed physicians to decide how intensely to treat each patient and how to individualize their treatment. Many older patients with diabetes have comorbidities and complications, which ultimately impact treatment decisions.
Endocrinology Consultant: What key conclusions were made in the new guideline? Were there any notable changes or updates?
Dr LeRoith: The mission of the committee that developed the guideline was to investigate studies that had yielded top-notch, clear-cut results and provided obvious directions regarding how to best treat older patients with diabetes. In the guideline, we also included some studies with findings that were perhaps less persuasive, and then we included expert opinion for areas that had little available evidence, which we indicated in the guideline. Studies that provided evidence for the guideline had examined the treatment of diabetes, as well as comorbidities and complications like hypertension, hyperlipidemia, issues related to kidney function, treating cardiovascular disease (CVD), and other complications that can occur. Evidence related to prevention of these complications was also included.
Ultimately, we were able to develop guidelines that suggest very strongly that in treating diabetes, bringing the hemoglobin A1c (HbA1c) down to a much lower level than was previously appreciated is very important in preventing complications. Similarly, treating blood pressure appropriately and treating lipid abnormalities with drugs like statins is very appropriate. Then, taking into account all these treatments I have mentioned, as well as follow-up visits for diabetic retinopathy and diabetic nephropathy, CVD, etc., we would adjust each patient’s treatment accordingly. For example, in a patient aged 85 years with diabetes with complications, we would not want to drop their HbA1c too low because this would lead to hypoglycemia, which is important to avoid in this patient population.
Another issue that comes up frequently is the degree of cognitive dysfunction patients with diabetes aged 70 to 75 years or older, which would affect patients’ ability to adhere to a therapy. Furthermore, older patients with frailty are prone to falls, so one would want to avoid the hypoglycemia and hypotension that could come about with very intensive therapy. On the contrary, one might have a patient aged 80 years who is very healthy in terms of physical and cognitive function. In this case, one could be more intensive in terms of therapy. This is where individualization of treatment comes into play.
Endocrinology Consultant: Were there any notable limitations in the evidence assessed in the statement that could inform future research endeavors?
Dr LeRoith: As I mentioned earlier, the guideline incorporated a large range of findings, and the strength of evidence varied as well. Although we had some evidence in the guideline that was very robust, some evidence mentioned in the guideline was not as clear-cut, and some areas with little to no evidence from studies were supported by expert opinion. All of the above suggested to us that there is room for a number of ongoing studies provide information in these areas.
In terms of specific topics, some studies have shown that patients with a long duration of diabetes often go on to develop cognitive dysfunction and even dementia more commonly than patients without diabetes. We need more trials examining this. Some evidence has also suggested that treating diabetes more intensively at a younger age can delay onset of cognitive dysfunction or dementia, but we need more trials in this area as well.
Endocrinology Consultant: What take-home message do you hope endocrinologists and other clinicians treating diabetes take away from this guideline?
Dr LeRoith: The first take-home message is that a team approach is key in treating diabetes, because a team approach seems to yield the best outcomes. This can include endocrinologists, primary care physicians, nurse educators, and other clinicians. Second, individualized therapy is very important. In other words, we need to intensify therapy to prevent long-term complications of diabetes in older patients, but at the same time, we want to be careful when determining how intensely to treat these patients in order to avoid any of the acute complications I mentioned earlier. It is important for health care professionals to know that this patient population needs care, but also that this care should be introduced very carefully.
—Christina Vogt
Reference:
LeRoith D, Jan Biessels G, Braithwaite SS, et al. Treatment of diabetes in older adults: an Endocrine Society* clinical practice guideline. J Clin Endocrinol Metab. 2019;104(5):1520-1574. https://doi.org/10.1210/jc.2019-00198