Need for Individualized Glycemic Goals for Older Adults with Type 2 Diabetes Highlighted

Older adults are at excess risk of adverse events from antidiabetic medications and have less time to benefit from tight glycemic control. Consequently, the American Diabetes Association (ADA) has relaxed glycemic goals for older patients ( Diabetes Care 2022 ).

Currently, glycated hemoglobin (HbA1c) targets are <7.5% for relatively healthy older adults, <8% for those with multiple chronic diseases, and avoidance of symptomatic hyperglycemia ( but not a specific target ) for those in very poor health. Additionally, the ADA states that "glycemic goals for some older adults could reasonably be relaxed as part of individualized care."

To assess whether clinical practice aligned with evolving guidelines between 2001 and 2018, researchers analyzed diabetes management in ≈3,500 US older adults (age, ≥65); Each HbA1c measurement was compared to the ADA glycemic goals in that year, based on the patient’s health status.

Between 2001 and 2018, the percentage of patients with HbA1c ≥1% below the goal for their health status increased from 16% to 43%. Half of the below-target patients were taking medications associated with hypoglycemia . Among patients with health problems taking diabetes medications, more than half had HbA1c ≥1% below target.

Although the exact optimal glycemic target is not always well defined, published evidence strongly supports the conclusion that targeting lower HbA1c levels may lead to better clinical outcomes for patients across the age spectrum.

Individualized Glycemic Goals for Older Adults Are a Moving Target. Scott J. Pilla, Zhinous Shahidzadeh Yazdi; Simeon I. Taylor. Diabetes Care 2022 ;45(5):1029–1031 https://doi.org/10.2337/dci22-0004

Landmark clinical studies demonstrate that intensive glycemic control reduces the risks of microvascular complications.
Although the question of how intensive glycemic control affects the risk of macrovascular complications is quite complex, long-term follow-up studies provide strong evidence that, over time, lowering HbA1c decreases the risk of events. adverse cardiovascular events.
Placebo-controlled trials have shown that SGLT2 inhibitors reduce the risks of major adverse cardiovascular outcomes, hospitalization for heart failure, and progression of diabetic nephropathy.
Placebo-controlled trials have shown that GLP-1 receptor agonists reduce the risks of major adverse cardiovascular outcomes, a clinical benefit that may be mediated by improved glycemic control.
Older patients obtain substantial cardiovascular benefits when treated with SGLT2 inhibitors or GLP-1 receptor agonists, possibly even greater than those of younger patients in the case of SGLT2 inhibitors.

Comment

Patients in poor health were most likely to have HbA1c well below target and to use hypoglycemic agents, suggesting a discrepancy between guidelines and clinical practice. Patients or physicians may be reluctant to de-intensify diabetes treatment, and physicians may add new diabetes medications that benefit patients’ comorbidities. However, patients in very poor health are unlikely to benefit from these medications or tight glycemic control, and deintensification should be prioritized for these individuals.

Need for Individualized Glycemic Goals for Older Adults with Type 2 Diabetes Highlighted

Despite relaxed glycated hemoglobin targets for older adults with type 2 diabetes, physicians appear slow to adjust their practices accordingly, prompting calls for individualized glycemic management strategies tailored to older patients’ needs.