Frequent Hypoglycemia Among Elderly Patients With Poor Glycemic Control

Munshi, Medha N.; Segal, Alissa R.; Suhl, Emmy; Staum, Elizabeth; DesRochers, Laura; Sternthal, Adrianne; Giusti, Judy; McCartney, Richard; Lee, Yishan; Bonsignore, Patricia; Weinger, Katie

doi:10.1001/archinternmed.2010.539

Cited by 170 publications

(125 citation statements)

References 14 publications

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“…Hypoglycemia was only slightly higher in those randomized to saxagliptin, although this excess has been shown to have occurred in those on background sulphonylureas and with a baseline HbA 1c ,7.0% (53.0 mmol/mol) (33). This finding is important because age is an independent risk factor for hypoglycemia (10,34,35). Furthermore, age-related comorbidities and severe oscillations in glucose levels in elderly patients due to poor or noncompliant management may increase the risk for hypoglycemia and may contribute to cognitive disorders and physical debilitation (35,36).…”

Section: Resultsmentioning

confidence: 99%

Efficacy and Safety of Saxagliptin in Older Participants in the SAVOR-TIMI 53 Trial

Leiter

Teoh²,

Braunwald

et al. 2015

Diabetes Care

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OBJECTIVETo examine the safety and cardiovascular (CV) effects of saxagliptin in the predefined elderly ( ‡65 years) and very elderly ( ‡75 years) subpopulations of the Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus-Thrombolysis in Myocardial Infarction 53 (SAVOR-TIMI 53) trial. RESEARCH DESIGN AND METHODSIndividuals ‡40 years (n = 16,492; elderly, n = 8,561; very elderly, n = 2,330) with HbA 1c ‡6.5% (47.5 mmol/mol) and £12.0% (107.7 mmol/mol) were randomized (1:1) to saxagliptin (5 or 2.5 mg daily) or placebo in a double-blind trial for a median follow-up of 2.1 years. RESULTSThe hazard ratio (HR) for the comparison of saxagliptin versus placebo for the primary end point (composite of CV mortality, myocardial infarction, or ischemic stroke) was 0.92 for elderly patients vs. 1.15 for patients <65 years (P = 0.06) and 0.95 for very elderly patients. The HRs for the secondary composite end points in the entire cohort, elderly cohort, and very elderly cohort were similar. Although saxagliptin increased the risk of hospitalization for heart failure in the overall saxagliptin population, there was no age-based treatment interaction (P = 0.76 for elderly patients vs. those <65 years; P = 0.34 for very elderly patients vs. those <75 years). Among saxagliptin-treated individuals with baseline HbA 1c ‡7.6% (59.6 mmol/mol), the mean change from baseline HbA 1c at 2 years was 20.69%, 20.64%, 20.66%, and 20.66% for those ‡65, <65, ‡75, and <75 years old, respectively. The incidence of overall adverse events (AEs) and serious AEs was similar between saxagliptin and placebo in all cohorts; however, hypoglycemic events were higher for saxagliptin versus placebo regardless of age. CONCLUSIONSThe SAVOR-TIMI 53 trial supports the overall CV safety of saxagliptin in a robust number of elderly and very elderly participants, although the risk of heart failure hospitalization was increased irrespective of age category. AEs and serious AEs as well as glycemic efficacy of saxagliptin in elderly patients are similar to those found in younger patients.Estimates place the global prevalence of diabetes in individuals between 60 and 79 years old at ;19%, with the number of these individuals projected to almost double by 2035 (1). Despite ongoing emphasis on the importance of practicing evidencebased medicine (2), older patients have been underrepresented in type 2 diabetes

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Section: Resultsmentioning

confidence: 99%

Efficacy and Safety of Saxagliptin in Older Participants in the SAVOR-TIMI 53 Trial

Leiter

Teoh²,

Braunwald

et al. 2015

Diabetes Care

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“…Fear of injections also increases patient reluctance about the initiation of insulin. Consistent with this finding, Munshi et al found that even after the recommendation of the American Geriatric Society for the elevation of targeted HgA1c levels to over 8%, hypoglycemia occurrence in this population is not precisely known and remains an area for further investigation (19).…”

Section: Discussionmentioning

confidence: 70%

What primary care physicians think about insulin initiation in type 2 diabetes:a field-based study

Ak¹,

Sucakli²,

Canbal³

et al. 2015

Turk J Med Sci

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Background/aim: A significant number of patients with type 2 diabetes mellitus require insulin and little is known about the possible physician-related factors that could cause a delay in the initiation of insulin treatment in patients with type 2 diabetes. This study aimed to evaluate those factors.Materials and methods: A total of 87 family physicians working at 36 family health centers in urban Malatya participated in our study on a voluntary basis. A self-administered survey form was structured to gather the views of the primary care physicians. The survey was developed based on a review of the literature. The survey consisted of Likert scale item questions regarding knowledge about the disease of diabetes mellitus and the views of the primary care physicians regarding insulin initiation for type 2 diabetic patients.Results: Almost half of the participants (42.5%, n = 37) felt incompetent in the starting dosage adjustment and 40.2% (n = 35) of the participants felt incompetent in maintaining the appropriate dosage adjustment. In terms of sex, female family physicians were found to be more uncertain about the timing of initiating insulin treatment for diabetic patients. Conclusion:This study shows the necessity of continuous education activities and interventions to promote motivation in family physicians to improve care of diabetic patients in primary care.

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“…A case study 117 involving the use of continuous glucose monitoring to measure hypoglycaemia in older adults with diabetes found that simply relaxing HbA 1c goals may not be adequate to protect frail older adults against hypoglycaemia. They found 'an unexpectedly high frequency of hypoglycaemic episodes in older adults with poor glycaemic control'; 117 this was true of those with type 2 diabetes as well as of those with type 1 diabetes. The authors concluded that there is a need for treatment regimens that better match patients' self-care abilities, although they did not explore further what such regimens might look like.…”

Section: Diabmentioning

confidence: 99%

“…The authors concluded that there is a need for treatment regimens that better match patients' self-care abilities, although they did not explore further what such regimens might look like. 117 …”

Section: Diabmentioning

confidence: 99%

Managing diabetes in people with dementia: a realist review

Bunn

Goodman

Jones

et al. 2017

Health Technol Assess

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BackgroundDementia and diabetes mellitus are common long-term conditions that coexist in a large number of older people. People living with dementia and diabetes may be at increased risk of complications such as hypoglycaemic episodes because they are less able to manage their diabetes.ObjectivesTo identify the key features or mechanisms of programmes that aim to improve the management of diabetes in people with dementia and to identify areas needing further research.DesignRealist review, using an iterative, stakeholder-driven, four-stage approach. This involved scoping the literature and conducting stakeholder interviews to develop initial programme theories, systematic searches of the evidence to test and develop the theories, and the validation of programme theories with a purposive sample of stakeholders.ParticipantsTwenty-six stakeholders (user/patient representatives, dementia care providers, clinicians specialising in dementia or diabetes and researchers) took part in interviews and 24 participated in a consensus conference.Data sourcesThe following databases were searched from 1990 to March 2016: MEDLINE (PubMed), Cumulative Index to Nursing and Allied Health Literature, Scopus, The Cochrane Library (including the Cochrane Database of Systematic Reviews), Database of Abstracts of Reviews of Effects, the Health Technology Assessment (HTA) database, NHS Economic Evaluation Database, AgeInfo (Centre for Policy on Ageing – UK), Social Care Online, the National Institute for Health Research (NIHR) portfolio database, NHS Evidence, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (Google Inc., Mountain View, CA, USA).ResultsWe included 89 papers. Ten papers focused directly on people living with dementia and diabetes, and the rest related to people with dementia or diabetes or other long-term conditions. We identified six context–mechanism–outcome (CMO) configurations that provide an explanatory account of how interventions might work to improve the management of diabetes in people living with dementia. This includes embedding positive attitudes towards people living with dementia, person-centred approaches to care planning, developing skills to provide tailored and flexible care, regular contact, family engagement and usability of assistive devices. A general metamechanism that emerges concerns the synergy between an intervention strategy, the dementia trajectory and social and environmental factors, especially family involvement. A flexible service model for people with dementia and diabetes would enable this synergy in a way that would lead to the improved management of diabetes in people living with dementia.LimitationsThere is little evidence relating to the management of diabetes in people living with dementia, although including a wider literature provided opportunities for transferable learning. The outcomes in our CMOs are largely experiential rather than clinical. This reflects the evidence available. Outcomes such as increased engagement in self-management are potential surrogates for better clinical management of diabetes, but this is not proven.ConclusionsThis review suggests that there is a need to prioritise quality of life, independence and patient and carer priorities over a more biomedical, target-driven approach. Much current research, particularly that specific to people living with dementia and diabetes, identifies deficiencies in, and problems with, current systems. Although we have highlighted the need for personalised care, continuity and family-centred approaches, there is much evidence to suggest that this is not currently happening. Future research on the management of diabetes in older people with complex health needs, including those with dementia, needs to look at how organisational structures and workforce development can be better aligned to the needs of people living with dementia and diabetes.Study registrationThis study is registered as PROSPERO CRD42015020625.FundingThe NIHR HTA programme.

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Frequent Hypoglycemia Among Elderly Patients With Poor Glycemic Control

Cited by 170 publications

References 14 publications

Efficacy and Safety of Saxagliptin in Older Participants in the SAVOR-TIMI 53 Trial

Efficacy and Safety of Saxagliptin in Older Participants in the SAVOR-TIMI 53 Trial

What primary care physicians think about insulin initiation in type 2 diabetes:a field-based study

Managing diabetes in people with dementia: a realist review

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