Older people with type 2 diabetes who are functionally independent should be managed following NICE guidelines.
There is widespread acceptance that the management of people diagnosed with type 2 diabetes needs to address issues of hyperglycaemia, high blood pressure and dyslipidaemia in order to reduce the microvascular and macrovascular complications of diabetes.
NICE has recently published its draft guideline on the management of type 2 diabetes.1 This guideline will replace the current guideline CG87 published in 2009. Some of the glucose lowering recommendations in the draft are proving to be controversial and have been criticised by diabetes healthcare professionals.2 This is discussed later in this article.
The new draft NICE guideline does not address issues of management specific to older people. There is an international guideline specifically concerned with type 2 diabetes management in older people which was published in December 2013 by the International Diabetes Federation (IDF). This guideline is freely downloadable from the IDF website.3 It gives recommendations for older people who are in the categories of either functionally independent or functional dependent with subcategories of dementia, frailty and end of life care (defined as last year of life) and provides much needed guidance in managing older people with type 2 diabetes and other comorbidities.
In the UK the prevalence of diabetes across all ages is around 6%.4 Prevalence rates increase in older age groups. In Europe diabetes affects 10–30% of people above pensionable age.5 The prevalence of diabetes in care homes in England is 25%.6 In all of these studies type 2 diabetes accounts for over 90% of all people with diabetes.
Some older people are fit, healthy, active and have type 2 diabetes as their only diagnosis. The management recommendations for this group should be similar to those applicable to younger people. In the UK these will be based on NICE guidelines. The new draft NICE guideline for type 2 diabetes1 recommends the following:
A HBA1c target of 48mmol/mol (6.5%), at diagnosis and for patients to be on one oral glucose lowering agent. A more realistic target of 53mmol/ mol (7.0%) is recommended when more than one oral glucose lowering therapy is introduced and where drugs that can produce hypoglycaemia are used. The guideline says that targets need to be customised to meet “the complexities of individual patient needs.” On reviewing the evidence for intensification of glycaemic control, the guidelines development group describes clear evidence for reduced risk of microvascular complications and amputations (at least in recently diagnosed patients). They say that “the jury is still out” regarding cardiovascular protection and there remain significant concerns regarding serious hypoglycaemia and its consequences, especially for older, longer-duration high-risk patients.
Blood pressure targets
The guidance recommends treating raised blood pressure if it is consistently above 140/80mmHg. The aim should be to reduce blood pressure to below 140/80mmHg or below 130/80mmHg if there is kidney, eye or cerebrovascular disease.
The NICE guidelines do not include recommendations for older people who are functionally dependent. Recommendations given in the IDF guideline on type 2 diabetes in older people are given below.
In functionally dependent patients the target should be between 7.0–8.0%/53–64mmol/mol. For frail patients it should be up to 8.5%/70mmol/mol and for patients with dementia up to 8.5%/70 mmol/ mol. Patients who are at the end of life symptomatic hyperglycaemia should be avoided.
Functionally dependent individuals should be managed to achieve a target blood pressure of less than 140/90mmHg. Those with frailty should have a target blood pressure of up to 150/90mmHg and for dementia patients, a target blood pressure of 140/90mmHg should be attempted. Among individuals with advanced dementia, strict control of blood pressure may not have any added advantage.
End of life
Unless the blood pressure readings are immediately life threatening, strict control of blood pressure may not be necessary, and withdrawal of blood pressure lowering therapy may be appropriate.
NICE guidelines stress the importance of a structured education programme at and around the time of diagnosis, with annual reinforcement and review. They outline the components of this programme and highlight the need for the appropriate training of the educators running the programme. They stress that dietary advice, integrated with a personalised diabetes management plan, which includes increasing physical activity and losing weight, are fundamental to type 2 diabetes management. Older people with no functional impairment should also be referred for structured education and have a personalised diabetes plan that includes increasing physical activity and weight loss.
The draft NICE guidelines have caused controversy in their glycaemic lowering therapy recommendations by:
- Recommending initial monotherapy with the drug repaglinide in the 15% or so of people in whom metformin is contraindicated or not tolerated
- Recommending pioglitazone as the second therapy option
- The complexity of the treatment recommendations and algorithms. It remains to be seen whether the draft recommendations will be modified in light of these criticisms.
International diabetes guidance, such as those from the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)7 recommend that metformin is the initial monotherapy of choice for most people with diabetes and that the choice of therapy to be added to metformin should be based on an individual assessment of needs. Issues of risks associated with hypoglycaemia and other drug interactions, disease duration, life expectancy, important comorbidities, established vascular complications, patient attitudes and expected treatment effects and resources and support system availability should influence the choice of second line therapy. A choice from all glycaemic lowering therapy groups may need to be considered.
The IDF guideline for older people3 recommends metformin as initial monotherapy of choice unless it is contraindicated through renal impairment or not tolerated. It recommends a range of options for second and third line therapy, but stresses the need to consider therapies with a low potential to cause hypoglycaemia.
Again this guidance is given in the IDF guideline,3 which says choices need to be made from a variety of medication groups and the following special considerations should be made:
- When prescribing an oral glucose lowering agent, choose one with a low potential for hypoglycaemia
- Use simplified insulin regimens with a low hypoglycaemic risk
- Avoid complex regimens and higher treatment burden to reduce the risk of medication errors
- Avoid or discontinue agents that might cause nausea or gastrointestinal disturbance or excess weight loss (eg. metformin or a glucagon-like peptide-1 receptor agonists). Insulin may provide anabolic benefit
- Consider appropriate withdrawal of therapy, including insulin, in the terminal phase.
The NICE guidance recommends first line antihypertensive therapy with a once daily generic angiotensin-converting enzyme (ACE) inhibitor. If there is continuing intolerance to an ACE inhibitor, substitute it with an angiotensin 11–receptor antagonist (ARB). An exception to this are people of African or Caribbean family origin who should have either ACE plus diuretic or a calcium channel blocker.
If the person’s blood pressure is not reduced to the agreed target with first line therapy, add a calcium channel blocker or a diuretic (usually a thiazide). Add a calcium channel blocker or diuretic if the target is not reached with dual therapy. The IDF guidelines3 have similar recommendations.
The IDF guideline3 provides the following special considerations:
- Diuretics can precipitate falls in vulnerable individuals and inconvenient micturition and should be prescribed with caution in the very frail or those with advanced dementia who have impaired mobility or balance
- Caregivers should be provided with sufficient knowledge and support to arrange the safe administration of blood pressure lowering therapy
- Pharmacotherapy should be approached with caution in people with advanced dementia with poor caregiver support, because of the risk of hypotension
- In the last year of life unless the blood pressure readings are immediately life threatening, strict control of blood pressure may not be necessary, and withdrawal of blood pressure lowering therapy may be appropriate
- If blood pressure lowering therapy is considered necessary, ACE inhibitors and ARBs remain the medicines of choice.
The IDF guideline has the following recommendations:
- Assessment of lipids is an integral part of cardiovascular risk assessment
- A full lipid profile, including total cholesterol, LDL-cholesterol, HDL-cholesterol, and triglycerides should be assessed initially and then at clinically relevant intervals
- Non-pharmacological interventions should include a dietary review taking into account the overall principles of nutrition in older people
- All older people with diabetes are at high CVD risk and should be considered for treatment with a statin unless contraindicated or considered clinically inappropriate
- Lower statin doses should be used and indications of side-effects (especially muscular and hepatic) or possible drug interaction monitored
- General lipid targets are as follows: LDL cholesterol <2.0mmol/l (<80mg/dl), triglyceride <2.3mmol/l (<200 mg/dl), HDL cholesterol >1.0mmol/l (>39mg/dl), non-HDL cholesterol <2.5 mmol/l (<97mg/dl). LDL cholesterol should be <1.8mmol/l (<70mg/dl) in established CVD
- Other lipid lowering therapies (fenofibrate, bile acid binding resins, ezetimibe, sustained release nicotinic acid, concentrated omega-3 fatty acids) may be appropriate in some individuals failing to reach lipid targets or intolerant of conventional medications. Niacin should be avoided in older people with diabetes.
The IDF guideline recommends that:
- Caregivers should be provided with sufficient knowledge and support to arrange the safe administration of lipid lowering therapy
- Statins should be used as clinically indicated, especially in individuals with established CVD. Carefully monitor for indications of statin muscular side-effects. Statins should not be combined with fibrates
- Lipid targets and frequency of lipid measurement can be relaxed
- The appropriateness of statin use in individuals with non-atherosclerotic dementia should be considered. Pharmacotherapy should be approached with caution in people with advanced dementia with poor caregiver support
- Lipid lowering therapy is not usually necessary in the last year of life and withdrawal of therapy may be appropriate.
Older people with type 2 diabetes who are functionally independent should be managed following NICE guidelines. New NICE guidelines have recently been published in draft form1 and their recommendations for glycaemia, and blood pressure are outlined above. The glucose lowering section is being criticised. The final guideline is due for publication in the summer of 2015 and it will be interesting to see if the draft will be modified in light of comments made.
Older people with functional impairment, frailty, dementia and who are in the last year of life have specific recommendations for management outlined in the IDF guideline3 and which are outlined in this article. If these recommendations are followed it may require that older individuals with functional impairment are excluded from Quality and Outcomes (QoF) clinical indicators on the basis that the QoF targets are medically inappropriate in people with these specific disabilities.
- In the UK the prevalence of diabetes across all ages is around 6%. Prevalence rates increase in older age groups
- If the person’s blood pressure is not reduced to the agreed target with first line therapy, add a calcium channel blocker or a diuretic (usually a thiazide)
- Some older people are fit, healthy and active and have type 2 diabetes as their only diagnosis
- If the recommendations outlined in this article are put into practice, older people with diabetes should be managed more appropriately
If the recommendations outlined in this article are put into practice, older people with diabetes should be managed more appropriately.
Professor Roger Gadsby, Principle Teaching Fellow, Warwick Medical School, University of Warwick
Conflict of interest: none declared
1. NICE. Type 2 diabetes: guideline consultation 2015. https:// www.nice.org.uk/guidance/gid-cgwave0612/resources/ type-2-di-abetes-guideline-consultation2 (Accessed 3 March 2015)
2. O’Hare P, Millar-Jones D, Hicks D, et al The new NICE guidelines for type 2 diabetes: a critical review BJDVD 2015 15 Issue 1– epublished ahead of print
3. IDF Guideline Type 2 Diabetes in Older People http://www. idf.org/guidelines/managing-older-people-type-2-diabetes (last accessed 3 March 2015)
4. Holman N, Young B, Gadsby R. What is the current prevalence of diagnosed and yet to be diagnosed diabetes in the UK. Diabetic Medicine 2014; 31: 510-511
5. DECODE Study Group. Age- and sex-specific prevalences of diabetes and impaired glucose regulation in 13 European cohorts. Diabetes Care 2003; 26: 61–9
6. Sinclair AJ, Gadsby R, Penfold S. Prevalence of diabetes in care home residents. Diabetes Care 2001; 24: 1066–8
7. Inzucchi SE, Bergenstal RM, Buse JB, et al Management of Hyperglycaemia in Type 2 Diabetes, 2015, A Patient Centered Approach. Update of the position statent of the ADA and EASD Diabetes Care 2015; 38: 140–149