case study long standing diabetes
TRANSCRIPT
Case Study of Elderly patient with Long Standing Diabetes
Prof. Alaa Wafa
Mr. AH Mr. AH is a 70-year-old man who was diagnosed with T2DM 10 years
ago. He was initially treated with lifestyle management and metformin. 3 years later, his doctors advised him to add long acting basal insulin
analogue to metformin, reached to 40U/day . Other current medical conditions include: hypertension, hypothyroidism,
and mild osteoporosis without fracture history. Current medications; Metformin 1000 mg bid, long acting basal insulin
analogue 40U/day , Candesartan 16 mg qd, Alendronate 70 mg once weekly, Levothyroxine 100 mg qd.
Physical exam: BMI 26 kg/m2, BP 140/80 mmHg, otherwise unremarkable.
His current FPG 140 mg/dL and HbA1c 8.5%. Kidney and liver functions are normal.
Does his age should be a concern and why ?
What Kind of Care should this patient receive specifically ?
Q1. Based on the patient's age, physical examination, history, and laboratory values, what is an appropriate glycemic target for him?
A. 9.0%B. 8.0%C. 7.0%D. 6.5%E. 7-8%
Q2. Do you think increasing insulin dose is the best choice for Mr. A.H.?
A. YesB. No
Data Support Benefits of Vildagliptin in Newly Diagnosed Diabetes Or Patients with Short
History of Diabetes
Do you think that, Using Vildagliptin is useful with patient with longstanding diabetes?
It is a big Population...
7.5% of Population
Worldwide
Adapted from http://www.indexmundi.com/egypt/demographics_profile.html , https://www.cia.gov/library/publications/the-world-factbook/geos/eg.html , http://en.worldstat.info/World accessed 22-2-2014
0.22.1
7.9
17.6
14.9
02468
101214161820
12-19 20-39 40-59 60-74 ≥75
High prevalence of T2DM in the elderly population
National Health and Nutrition Examination Survey (NHANES) 2005-2006.T2DM=type 2 diabetes mellitus. Adapted from Cowie CC, et al. Diabetes Care. 2009; 32: 287–294.
%
Age (years)
Worldwide, the elderly population
in developed regions will nearly
double by 2050
Increasing in the proportions of older persons (60 years or older)
2013
≥60 Years ≤60 Years
International Diabetes Federation. Managing Older People with Type 2 Diabetes Global Guidelines. http://www.idf.org/sites/default/files/IDF%20Guideline%20for%20Older%20People.pdf accessed 15-12-2013
2050
≥60 Years ≤60 Years
These changes present significant challenges to welfare, pension, and healthcare systems in both developing and developed nations
Diabetes-related complications are common in the elderly
• Diabetes-related complications are the major causes of morbidity, disability and mortality in older patients with type 2 diabetes:
• There is now overwhelming evidence that the level and duration of glycemia influences the development of diabetes-related complications
Sinclair 2004. Clinical guidelines for type 2 diabetes mellitus. EDWOP 2004
Microvascular: Neuropathy,Retinopathy,Nephropathy
Macrovascular: Cardiovascular disease, Stroke
Rates of Complications and Mortality in Older Patients With Diabetes Mellitus
(1/3)• The Diabetes and Aging Study:To contrast the rates of diabetes complications and mortality across age and diabetes duration categories.
• Design: This cohort study (2004-2010) included 72 310 older (60 years) patients with type 2 diabetes enrolled in a large, integrated health care delivery system.
Huang ES, et al. JAMA Intern Med. Rates of Complications and Mortality in Older Patients With Diabetes Mellitus. The Diabetes and Aging Study. 2013 Dec 9. [Epub ahead of print]
Rates of Complications and Mortality in Older Patients With Diabetes Mellitus
(2/3)
*Acu
te hy
pergl
ycem
ic ev
ent
*Acu
te hy
pogly
cemic
even
t
*End
-stag
e ren
al dis
ease
*Eye
dise
ase
*Peri
phera
l vas
cular
dise
ase
0
5
10
Age 60-69 yAge 70-79 yAge ≥80 y
Eve
nts p
er 1
000
Pers
on-y
ears
Huang ES, et al. JAMA Intern Med. Rates of Complications and Mortality in Older Patients With Diabetes Mellitus. The Diabetes and Aging Study. 2013 Dec 9. [Epub ahead of print]
*P Value < 0.0001All groups VS No morbidities
Rates of Complications and Mortality in Older Patients With Diabetes Mellitus
(3/3)
Corona
ry art
ery di
seas
e
Cerebro
vasc
ular d
iseas
e
Conge
stive
heart
failu
re
Mortali
ty0
20406080
100120
Age 60-69 yAge 70-79 yAge ≥80 y
Huang ES, et al. JAMA Intern Med. Rates of Complications and Mortality in Older Patients With Diabetes Mellitus. The Diabetes and Aging Study. 2013 Dec 9. [Epub ahead of print]
Even
ts p
er 1
000
Pers
on-y
ears
*P Value < 0.0001All groups VS No morbidities
Conclusion: Duration of diabetes and advancing age independently
predict diabetes morbidity and mortality rates
56% of health care expenditure attributed to diabetes is incurred by the
elderly populationCost in US$ millions
Institutional care Outpatient care Outpatient medicines and supplies
<45 years 45-64 years ≥65 years
American Diabetes Association. Diab Care 2008;31:596-615
Good glycemic control reduces the risk of long-term complications of diabetes
1. Stratton et al. BMJ 2000 ; 321 : 405-12 2. Turner et al. JAMA 1999 ; 281 : 2005-12
-43%-37%
-21%
-50%
-40%
-30%
-20%
-10%
0%
Reduction in long-term complication with every 1% reduction in HbA1c
Reductionin peripheral
vascular disease
Reductionin Microvascular
disease
Reductionin death related
to type 2 diabetes
The management of T2DM in the elderly is challenging
Ageing, diabetic microvascular and macrovascular complications, hyperglycaemia, hypoglycaemia, multiple morbidity and lack of
social support are risk factors for the geriatric syndromesT2DM=type 2 diabetes mellitus.Araki A, Ito H. Geriatr Gerontol Int. 2009; 9: 105–114.
Ageing
Diabetescomplications
Comorbidity
Lack of social support
Hyperglycaemia
Hypoglycaemia
Increasedmortality
Depression
Disability
Malnutrition
Urinary incontinence
Cognitive impairment
Falling
Risk factors Geriatric syndromes
Cognitive decline
Depression
Intoleranceto side effects
The achievement of good glycemic control in the elderly is challenging
Poor
Gly
cem
ic C
ontr
ol
“Frailty”
Co-morbidities
Poly-pharmacy
Compromised renal function
1. Gregg et al. Arch Intern med 2000 ; 160 : 174-80; 2. Ott et al. Diabetologia 1999 ; 53 : 1937-423. Rockwood et al. Drugs Aging 2000 ; 17 : 295-302; 4. Wolff et al. Arch Intern med 2002 ; 162 : 2269-765. Shorr et al. Arch Intern med 1997 ; 157 : 1681-6
Hypoglycaemia is a major challenge in the treatment of diabetes in the
elderly
• Advanced age• Recent hospitalization• Intercurrent illness• Chronic liver, renal or
cardiovascular disease• Endocrine deficiency
(thyroid, adrenal, pituitary)• Loss of normal counter-
regulation• Hypoglycaemic
unawareness
SU=sulfonylurea.Adapted from Chelliah A, Burge MR. Drugs Aging. 2004; 21: 511–530.
I. Patient risk factors • Poor nutrition or fasting• Prolonged physical
exercise• Alcohol (ethanol)
• Use of SU and / or insulin• Drug interactions with SUs
III. Drug risk factors
II. Lifestyle risk factors
Severe hypoglycaemia accounts for almost 20% of all hospitalizations for
T2DM in the elderly
T2DM=type 2 diabetes mellitus.Greco D, et al. Exp Clin Endocrinol Diabetes. 2010; 118: 215–219.
Decompensated diabetes
39%
Intercurrent illness14%
Acute cardiovascular
events13%
Chronic complications
of diabetes1
Severe hypoglycaemia
17%
The risk of hypoglycaemia can increase due to drug interactions with
SUs
MAOI=monoamine oxidase inhibitor; SU=sulfonylurea.Adapted from Chelliah A, Burge MR. Drugs Aging. 2004; 21: 511–530.
Displacement of SUs from the
plasma proteins
Reducing the hepatic
metabolism of SUs
Decreasing the urinary excretion
of SUs or their metabolites
The consequences of hypoglycaemia
Cardiovascularcomplications3
Weight gain by defensive eating5
Coma3
Increased risk of car accident6
Hospitalisation costs4
Loss of consciousness3
Increased risk of seizures3
Death2,3
Increased risk of dementia1
1Whitmer RA, et al. JAMA. 2009; 301: 1565–1572; 2Bonds DE, et al. BMJ. 2010; 340: b4909; 3Barnett AH. Curr Med Res Opin. 2010; 26: 1333–1342; 4Jönsson L, et al. Value Health. 2006; 9: 193–198;5Foley JE, Jordan J. Vasc Health Risk Manag. 2010; 6: 541–548; 6Begg IS, et al. Can J Diabetes. 2003; 27: 128–140; 7McEwan P, et al. Diabetes Obes Metab. 2010; 12: 431–436.
Reduced quality of life7
Hypoglycaemia
So, Management challenges can lead to cautious prescriptions
in the elderly
1. Market research, data on file, Novartis.2. Cryer PE. Diabetes 2008; 57: 3169-76
Hypoglycemia
Other factors
Glycemic targets
Man
agem
ent c
halle
nges
?• Glycemic targets for elderly with long-standing or
more complicated disease should be less ambitious than for the younger, healthier individuals
• If lower targets cannot be achieved with simple interventions, an HbA1c of 7.5–8.0% may be acceptable, transitioning upward as age increases and capacity for self-care decline
> 65 Years
Older adults who are functional, cognitively intact, and have significant life expectancy
should receive diabetes care with goals similar to those developed for younger
adults. (E)
Glycemic goals for some older adults might reasonably be relaxed, using
individual criteria, but hyperglycemia leading to symptoms or risk of acute
hyperglycemic complications should be avoided in all patients. (E)
ADA 2014: Treatment Goals according to health status