Building Competency in Diabetes Education THE ESSENTIALS

TREATMENT MODALITIES: PHARMACOLOGICAL THERAPIES | 6-52

• The lean older person with type 2 diabetes is more likely to be insulin deficient while the person with obesity and type 2 diabetes will be insulin resistant. • Metformin remains first-line treatment unless contraindicated. • DPP-4 inhibitors are preferred as second-line treatment over sulfonylureas as they promote glucose-dependent insulin secretion without causing hypoglycemia, achieve similar glycemic control and have been shown to be safe to use in older people. • Persons with clinical cardiovascular disease, chronic kidney disease, heart failure, or if over age 60 with 2 or more CV risk factors can be treated with an antihyperglycemic agent with demonstrated cardiorenal benefit • GLP-1 receptor agonists are generally well tolerated in the elderly and have similar adverse events, but the elderly may be at risk for higher GI side effects. The choice of insulin therapy should also be individualized with the following considerations: • Once-daily basal insulin is the preferred treatment, using long-acting basal insulin analogues. • Premixed insulin analogues have been shown to provide better glycemic control than basal insulin and equivalent glycemic control to basal-bolus insulin regimens; however, at the risk of more hypoglycemia and weight gain. o Premixed insulin analogues can be given after meals prn • Basal-bolus insulin regimens are associated with greater improvements in glycemic control,

mood, and health than twice daily long-acting basal insulin therapy. • Insulin metabolism is decreased when eGFR is <50mL/min /1.73m 2 .

Ongoing evaluation of the treatment plan and diabetes self-care management is required as people age and with changes in medical or functional status. Refer to Chapter 4: Changes Across the Lifespan, for more information on providing the best care of the older individual with diabetes.

Drug interactions Common drugs may also interact significantly with antihyperglycemic agents or affect an individual’s level of glycemic control. People with diabetes should be advised to clarify any possible interactions or effects of newly prescribed medications on their diabetes management. Even simple, over-the-counter medications can have negative effects on glycemic control. Asking a pharmacist for information can help people with diabetes avoid unnecessary drug interactions and adverse events. An adjustment in their dose of antihyperglycemic agents or insulin may be necessary in order to achieve or maintain BG targets.