#1: Understand the Targets

A completely “healthy” older adult may aim for a “great” Hemoglobin A1c (HbA1c), i.e. <6.5%, “as long as significant hypoglycemia does not become a barrier”. ⁹ This statement from the American Diabetes Association requires the fullest attention of any provider managing diabetes in an older adult. It is essential to recognize that HbA1c is an average, and it has to be interpreted as such.

The following table is based on the estimate average glucose equivalent (eAG) per HbA1c.¹⁰

A target HbA1c of 7.5% is an average equivalent eAG of 169mg/dl. The range of values making up that average is crucial.  Patients with very similar characteristics, and thus same HbA1c target, can have two completely different scenarios:

• Patient A has morning fasting glucose values around 120mg/dl, and the rest of the day values around 160mg/dl.  He is on target and well controlled.

• Patient B has values ranging from 50 to 200, and has the same HbA1c on laboratory test results.  Here, the “on target” HbA1c would be at the expense of hypoglycemic events, putting the patient at risk.

#2: Understand your Patient

Hypoglycemic events require a clear understanding of their etiology to prevent/avoid recurrence.

• Did the patient accidently forget that he had injected the correct dose (thereby injecting twice)?

• Was he interrupted during a meal and could not finish eating?

• Is the event a marker of cognitive decline?

• Was there a different reason?

   

In patients with cognitive decline or other functional loss (e.g. vision, dexterity), the situation is beyond the pharmacokinetics/ pharmacodynamics, and dosage and effect of medication and requires exploration of non-formal (i.e. family, caregivers, friends) or formal (i.e. home health nurse) assistance. 

#3: Prevent Hypoglycemic Events

Severe hypoglycemia is defined as any hypoglycemic event associated with loss of consciousness and/or the need for assistance.  It is the provider’s responsibility to address those events and to try to prevent future events. The following are initial steps:

• Understand the safety profile of pharmacologic agents ⁸

  • < > The Beers’ criteria ¹² for medications identify glyburide as a “no-no” option for managing diabetes in older adults given an increased risk of hypoglycemia.  We recommend discontinuing glyburide in any older adult, review the prior 2 recommendations, switching to the “safer” sulfonylureas if an agent is still indicated. Caution is still recommended, especially in patients with renal or hepatic impairment. If possible, use a non-sulfonylurea agent with less hypoglycemic risk, especially if in combination with insulin. Once a patient requires a basal bolus regimen, hence relying in exogenous insulin, an insulin secretagogue may add little benefit, hence sulfonylureas are not to be added to basal bolus regimen, and ought to be removed from the medication list.
    

    Alpha-glucosidase inhibitors: while the use of miglitol or acarbose is limited, given their tolerability and modest HbA1c reduction (0.5-1%), they are reasonable agents for a few selected cases. These agents still have mild hypoglycemic risk, which is increased when in combination with sulfonylureas.

  • Glucagon-like peptide-1 receptor agonists: these agents may be helpful in weight reduction, a critical component for management of type 2 diabetes,  however, they present a risk for hypoglycemia and require proper monitoring.

  • < > while synthetic insulins (long-acting and short-acting) may not be as effective in lowering glucose than older non-synthetic (neutral protamine Hagedorn or regular insulin), the former may be associated with less hypoglycemia.^13,14
    

    Adjust medicationsto decrease hypoglycemic risk

    • An older person with an HbA1c of ~7.5% would have a corresponding eAG of ~169.If this person has glucometer blood glucose readings close to, or below, 100mg/dl, that indicates the patient must have some values above 200mg/dl (to make up for the eAG).Yet, more concerning, the low normal values are too close to the threshold for hypoglycemia. This is a key item to recognize, as the medication regimen ought to be decreased to avoid future hypoglycemia.

       

  • Recognize risk for hypoglycemia during transitions of care

    • Careful monitoring at each care transition (e.g. home to hospital, hospital to nursing home, nursing home to home) is essential to avoid medication errors and hypoglycemia.

    • Anticipate increased glucotoxicity (e.g., due to infection, steroids, stress or pain). While there can be a temporary need to increase pharmacologic interventions, when the initial insult “cools down”, medication doses may need to be decreased.