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Care of the Aging Patient: From Evidence to Action |

Polypharmacy in the Aging Patient A Review of Glycemic Control in Older Adults With Type 2 Diabetes

Kasia J. Lipska, MD, MHS1; Harlan Krumholz, MD, SM2,3,4; Tacara Soones, MD, MPH5; Sei J. Lee, MD, MAS6,7
[+] Author Affiliations
1Department of Internal Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, Connecticut
2Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
3Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Yale School of Medicine, New Haven, Connecticut
4Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
5Department of Geriatrics and Palliative Medicine; Icahn School of Medicine at Mount Sinai; New York
6Division of Geriatrics, Department of Medicine, University of California, San Francisco
7San Francisco VA Medical Center, California
JAMA. 2016;315(10):1034-1045. doi:10.1001/jama.2016.0299.
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Importance  There is substantial uncertainty about optimal glycemic control in older adults with type 2 diabetes mellitus.

Observations  Four large randomized clinical trials (RCTs), ranging in size from 1791 to 11 440 patients, provide the majority of the evidence used to guide diabetes therapy. Most RCTs of intensive vs standard glycemic control excluded adults older than 80 years, used surrogate end points to evaluate microvascular outcomes and provided limited data on which subgroups are most likely to benefit or be harmed by specific therapies. Available data from randomized clinical trials suggest that intensive glycemic control does not reduce major macrovascular events in older adults for at least 10 years. Furthermore, intensive glycemic control does not lead to improved patient-centered microvascular outcomes for at least 8 years. Data from randomized clinical trials consistently suggest that intensive glycemic control immediately increases the risk of severe hypoglycemia 1.5- to 3-fold. Based on these data and observational studies, for the majority of adults older than 65 years, the harms associated with a hemoglobin A1c (HbA1c) target lower than 7.5% or higher than 9% are likely to outweigh the benefits. However, the optimal target depends on patient factors, medications used to reach the target, life expectancy, and patient preferences about treatment. If only medications with low treatment burden and hypoglycemia risk (such as metformin) are required, a lower HbA1c target may be appropriate. If patients strongly prefer to avoid injections or frequent fingerstick monitoring, a higher HbA1c target that obviates the need for insulin may be appropriate.

Conclusions and Relevance  High-quality evidence about glycemic treatment in older adults is lacking. Optimal decisions need to be made collaboratively with patients, incorporating the likelihood of benefits and harms and patient preferences about treatment and treatment burden. For the majority of older adults, an HbA1c target between 7.5% and 9% will maximize benefits and minimize harms.

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Framework to Individualize Glycemic Treatment Decisions in Older Adults
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