Irrespective of the patients age, clinicians have access to and can prescribe medications that are optimal for patients with T2DM. "Particularly those that don't cause hypoglycemia," Dr. Olansky explained. "Those are the agents I try to use first anyway." These include metformin, GLP-1 agonists, DPP-4 inhibitors, and, most recently, SGLT-2 inhibitors. "These don't cause weight gain. Most of the GLP-1 and SGLT-2 inhibitors tend to be associated with some weight loss. They don't cause hypeglycemia," she explained.
"Those are agents that ultimately I think can probably change the course of type 2 diabetes and help protect beta cells and lead to fewer type-2 patients needing insulin, which I think is a good goal," said Dr. Olansky.
As T2DM patients age and develop co-morbidities, clinicians should try to avoid drugs that cause fluid retention, Dr. Olansky suggested. These can include TCDs, insulin, sulfonylureas. "If patients develop significant renal disease we can't use metformin and we can't use the SGLT-2 inhibitors, but we can use the other classes of drugs."
"The main concern I have about the older patient is the risk of hypoglycemia, which is much less well tolerated in an older patient. I think our hemoglobin A1c targets are not as low as in a person who is only expected to live another 15 or 20 years compared to someone who we expect is going live another 50 years, where the gains of better control are more likely to be realized and therefore a little more risk might be worth taking if a patient is subject to some increased risk. That's my strategy as patients get older. I put a little less effort into lower hemoglobin A1c -- although the older patient who can be maintained at 6.5 without hypoglycemia, I have no objection to that," Dr. Olansky explained.
"Overall, it's very similar across the age spectrum, I just have a little more caution with the older patients if they do have co-morbidities or if I'm stuck with therapy that is going to put them at ," she added.