Information intended for UK healthcare professionals only.

This summary was developed by Guidelines and Dr Strain, based on the guidance developed by Strain WD et al., with the support of a sponsorship from Novo Nordisk UK. See end of summary for full disclaimer.

 

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[A] Saxagliptin has been associated with an increased risk of symptomatic heart failure. [B] At time of publication, any SGLT-2i can be initiated at eGFR>60 ml/min/1.73 m2 for the management of hyperglycaemia: canagliflozin can be initiated at >45 ml/min/1.73 m2 or >30 ml/min/1.73 m2 in people with proteinuria, dapagliflozin can be initiated at any HbA1c for the management of heart failure. All SGLT-2i are less efficacious at reducing hyperglycaemia at lower eGFRs. [C] Expert recommendation.

Overview

  • This Guidelines summary provides the key points for primary care. Please refer to the full guideline for the complete set of recommendations and a review of the evidence.

Background and aims

  • This guidance aims to provide prescriptive guidance for glycaemic management in older adults with diabetes, according to frailty, including frailty-specific glycaemic targets
  • For the assessment of frailty in older adults with type 2 diabetes, and on appropriate glucose target setting, please refer to the Guidelines summary on Type 2 diabetes mellitus in older people
  • Detailed advice is needed for healthcare professionals caring for older people with diabetes on how to safely prescribe newer glucose-lowering therapy, and when to intensify or de-escalate treatment
  • In order to overcome treatment inertia, it is important to provide guidance on de-prescribing/de-escalation, and to highlight the complications and comorbidities of type 2 diabetes in older adults that should be considered as part of a holistic management and multifactorial management approach
  • Medical, psychological, and functional issues such as sarcopenia, heart failure, hypertension, lipid profile, urinary incontinence, cognitive decline, depression, diet, physical condition, falls and fractures, swallowing difficulties, an increased need for assistance with administration of medication by carers or care home staff, and polypharmacy can all impact upon adherence and the pharmacodynamic response to glucose-lowering therapies.

Degrees of frailty and treatment goals in older adults with type 2 diabetes

  • Frailty is not a simple correlate of age, necessarily progressive, nor irreversible.2 Some older adults with diabetes have numerous diabetes-related comorbidities, limited cognitive or physical functioning, and a severe degree of frailty, whereas others may have few or no comorbidities and be very active with only a mild degree of frailty 
  • Prognosis and hence appropriate diabetes treatment goals for older adults with diabetes vary greatly according to frailty and therefore need to be individualised.3 For example, older and more frail people with diabetes who have significant comorbidity or substantial cognitive or functional impairments are less likely to live long enough to reap the benefits of long-term intensive diabetes management, such as a reduced risk of vascular complications. They are also more likely to suffer serious adverse effects from hypoglycaemia
  • A further issue to consider when assessing HbA1c in older adults is the accuracy of the metric itself. There are multiple comorbidities that confound glycated haemoglobin (see Table 1)
  • Once established, apart from age and gender, frailty is the single biggest predictor of mortality in older adults.4 As a result, frailty, rather than comorbidity, underpins target setting, recommended interventions and treatment goals in older adults with diabetes (see Table 2)
  • It is important to remember that frailty is a dynamic process; a patient’s frailty categorisation may change. Re-evaluation of frailty should occur, as a minimum, at the annual diabetes review but earlier if there has been a change in health status and three months after any intervention (escalation or de-escalation), and targets may need to be re-evaluated based on development and diagnosis of co-existing chronic illnesses, cognitive function, and functional status.
Table 1: Known modifiers of HbA1c older adults  

Artificially increases HbA1c

(higher risk of hypoglycaemia if aggressive targets established)

Artificially reduces HbA1c

(higher risk of complications of hyperglycaemia and hyperosmolarity)

Iron deficiency

Bleeding conditions (e.g. peptic ulcer disease)

B12 deficiency

Haemolytic conditions (e.g. valvular cardiac disease)

Anaemia of chronic disease

Haemoglobinopathies (e.g. thalassaemia, sickle cell)

Chronic opioid use

Chronic liver disease

HbA1c =glycated haemoglobin.
Table 2: Target setting, recommended intervention, and treatment goals according to frailty[H] in older adults
 

Status

Treatment goals

Recommended interventions

Recommended targets

Healthy/pre frail/mild frailty

  • Functional and independent 
  • Life expectancy of >10 years
  • Reverse frailty or limit its progression
  • Maintain functional status, independence, and QoL
  • Prevent or delay macro/microvascular complications
  • Tight glycaemic control 
  • Resistance exercise and nutritional interventions 
  • Statin unless contraindicated/not tolerated
  • HbA1c <58 mmol/mol (<7.5%), but ≥42 mmol/mol (≥6%)
  • FPG 5.0–7.2 mmol/l 
  • BP <140/90 mm Hg

Moderate frailty

  • >2 comorbidities
  • Reduced life expectancy
  • Prevent decline in QoL
  • Limit the progression of microvascular complications
  • Avoid metabolic emergencies such hypoglycaemia
  • Glycaemic control 
  • Assess and reduce cognitive decline 
  • Statin unless contraindicated/not tolerated
  • HbA1c  <64 mmol/mol (<8.0%)
  • FPG 5.0–8.3 mmol/l 
  • BP <140/90 mm Hg

Severe frailty

  • Significant comorbidity and functional deficits, and limited independence
  • Markedly reduced life expectancy 
  • Improve QoL by reducing symptoms or hospitalisations
  • Maintain functional status, preventing further lower limb dysfunction, preventing significant disability
  • Less aggressive glycaemic targets but avoid hypoglycaemia and be aware that hyperglycaemia can increase risk of infections and cause urinary incontinence, thirst, and dehydration
  • Consider whether statin therapy is beneficial
  • HbA1c <69 mmol/mol (<8.5%) 
  • FPG 5.6–10.0 mmol/l
  • BP <150/90 mm Hg

[H] A significant part of clinical decision making in older people with diabetes involves consideration of their frailty status, but this will vary in importance depending on the presence of other factors including severe comorbidity, vascular complications and cognitive impairment. BP=blood pressure; FPG=fasting plasma glucose; HbA1c =glycated haemoglobin; QoL=quality of life.

Table 3: Pros and cons of anti-diabetic therapies for the treatment of type 2 diabetes in older adults

For a review of the available therapies, please refer to the full guideline

 

Pro

Con

Metformin

Alters mitochondrial cell energetics to inhibit gluconeogenesis, oppose the action of glucagon, and increase insulin sensitivity5

  • Inexpensive
  • jjjjWell established, generally well tolerated standard therapy 
  • Potential CV benefit (demonstrated in UKPDS study)6
  • Low hypoglycaemia risk
  • Can be combined with all other diabetes therapies 
  • Reduced appetite and gastrointestinal disturbance
  • Possible association with vitamin B12 deficiency7
  • Moderate weight loss seen in some patients may be undesirable with frailty
  • Contraindicated in renal impairment
  • Should be used with caution in those with impaired hepatic function or cardiac failure, due to increased risk of lactic acidosis

Sulphonylureas and glinides

Stimulate pancreatic insulin secretion regardless of blood glucose concentration8

  • Inexpensive 
  • Can be combined with other therapies
  • Increased potency in older adults may sometimes be beneficial
  • Require functioning beta cells
  • Hypoglycaemia risk9
  • Increased potency following weight loss (with improved insulin sensitivity) may further increase hypoglycaemia risk

DPP-4 inhibitors

Inhibit breakdown of endogenous GLP-1, which glucose-dependently stimulates insulin secretion and inhibits glucagon secretion8

  • Well tolerated 
  • Formally tested in older adults10
  • May delay disease progression if used early with metformin 
  • Low risk of hypoglycaemia11
  • Safe in all stages of renal failure, at an appropriate dose 
  • No effect on weight
  • Moderate glucose lowering efficacy 
  • Neutral effect (apart from saxagliptin) on CV death, MI, stroke, and hospitalisation for heart failure,12 in contrast to SGLT-2is and GLP-1 RAs 
  • Possible issues with increased hospitalisation for heart failure, with saxagliptin (± alogliptin)13 
  • Relatively expensive

SGLT-2 inhibitors

Inhibit reabsorption (from renal tubules) of glucose, leading to increased urinary glucose output and osmotic diuresis14

  • CVOTs have shown reduction in MACE15
  • Benefits demonstrated for people with diabetes and heart failure12
  • Potential benefit in reducing progression of renal impairment16
  • Low hypoglycaemia risk
  • Weight loss could result in sarcopenia  
  • Risk of candidiasis
  • Potential increased urinary incontinence
  • Lack of glucose-lowering efficacy if established renal impairment17
  • Risk of euglycaemic diabetic ketoacidosis
  • Fluid volume depletion

GLP-1RAs

Stimulate insulin secretion, inhibit glucagon secretion, and also reduce appetite. GLP-1 RAs work in a glucose-dependent manner8

  • CVOTs have shown CV benefits with some, particularly in patients with ASCVD, and those at high risk of CV events15,18
  • Renoprotective effects16 
  • Low hypoglycaemia risk despite good glucose-lowering efficacy
  • Once-weekly administration possible with some19
  • A once-daily oral formulation of semaglutide is now available20
  • Weight loss could result in sarcopenia
  • Nausea is common, and reduced appetite could be problematic
  • Most are given by s.c. injection 
  • Relatively expensive

TZDs

Increase cellular expression of glucose transporters, thereby increasing insulin sensitivity and peripheral glucose uptake21

  • Generally well tolerated 
  • Low hypoglycaemia risk
  • Potential CV benefit with pioglitazone22
  • Fluid retention may exacerbate heart failure23 
  • Risk of osteoporosis and fractures24–26 
  • Ongoing debate regarding risk of bladder cancer27

Exogenous basal insulin

Binds to insulin receptors in liver to inhibit glycogenolysis and gluconeogenesis, and binds to peripheral insulin receptors (muscle, adipose) to stimulate glucose uptake

NPH insulin28

  • Established efficacy 
  • Inexpensive 
  • Requires resuspension
  • Need for twice daily injections
  • Weight gain (limited harm)
  • Hypoglycaemia risk
  • Variable glucose-lowering effect from injection to injection

First generation basal insulin analogues12

Insulin glargine

Insulin detemir 

  • Established efficacy 
  • Lower hypoglycaemia risk than NPH insulin
  • Cost lower than ultra-long acting insulins
  • Once daily injection possible
  • Insulin detemir associated with relatively little weight gain
  • Requirement for injection at same time each day may be problematic 
  • Hypoglycaemia risk 

Ultra-long acting insulin analogues29

Insulin degludec

Insulin glargine U300

  • Established efficacy 
  • Increased dosing flexibility
  • Lower hypoglycaemia risk than other basal insulins
  • Stable glucose-lowering action
  • More expensive than other basal insulins (possibly offset by reduced need for nurse visits ± reduced doses and longer lasting pens)

ASCVD=atherosclerotic cardiovascular disease; CV=cardiovascular; CVOT=cardiovascular outcome trial; DPP-4=dipeptidyl peptidase-4; GLP-1=glucagon-like peptide 1; GLP-1RA=glucagon-like peptide 1 receptor agonist; NPH=neutral protamine Hagedorn; PROactive=PROspective pioglitAzone Clinical Trial In macroVascular Events; SGLT2is=sodium/glucose cotransporter-2 inhibitors; s.c=subcutaneous; TZD=thiazolidinedione; UKPDS=UK Prospective Diabetes Study. 

Hypoglycaemia in older adults with diabetes

  • In frail older adults, hypoglycaemic symptoms such as dizziness, confusion, and visual disturbances, which often present more commonly than adrenergic symptoms (palpitations, sweating, tremors), can be mistaken for dementia or neurological problems30,31
  • Older adults with type 2 diabetes are more prone to hypoglycaemia as a result of various factors including polypharmacy,32,33 endocrine deficits, suboptimal water and food intake, and cognitive impairment, as well as cardiovascular disease (CVD) and renal dysfunction32,34,35
  • In addition to being at increased risk of hypoglycaemia, frail older adults are more vulnerable to its consequences. Hypoglycaemia in older people increases the risk of serious outcomes such as falls, fractures, cognitive decline, hospitalisation, CV events (thought to involve cardiac conduction disturbances), and all-cause mortality36
  • The avoidance of hypoglycaemia must be a paramount concern in the diabetes management of the frail older adult, and it cannot be assumed that regimens previously well tolerated in this respect will remain so. The treatments for type 2 diabetes with the greatest propensity for causing hypoglycaemia are insulin and the insulin secretagogues—sulphonylureas (SUs) and glinides (see Table 3).

Glycaemic management in older adults with diabetes, according to frailty

  • The choice of agents in the management of diabetes in older adults should be based on frailty status and the extent of co-existing chronic illness and cognitive and functional status11,37,38 
  • It is recommended to follow the simple glycaemic management algorithm depicted in (Figure 1) for older adults with type 2 diabetes, according to their level of frailty
  • Individuals may already be receiving treatment with metformin, SUs, or their combination plus or minus basal or premix insulin. In some cases, discontinuation of certain drugs is advocated, but with suitable replacements suggested. When escalating therapy, the risk of hypoglycaemia should be considered for those on insulin or SUs. It is not necessary to automatically discontinue an SU if there is no evidence of hypoglycaemia, although the dose should be reduced in the short term. For people on neutral protamine Hagedorn (NPH) or premix insulin, switching to a basal insulin analogue (glargine, detemir, or degludec) with a DPP-4i can be considered.

Treatment simplification/de-escalation guidance in the glycaemic management of older adults with diabetes 

  • As a person with diabetes gets older, regimen simplification, switching or de-escalation may be necessary, depending on their level of frailty and HbA1c levels. When contemplating modification of a diabetes regimen, it is helpful to conduct a basic audit of the status of the person with diabetes. An individual at advanced age (e.g., ≥75 years), identified as being moderately or severely frail, with an HbA1c value <53 mmol/mol (<7.0%) would suggest a high risk of occurrence of complications from hypoglycaemia. Consideration should be given to de-escalation of therapies that may induce this feared complication, such as SUs, or SU and insulin combinations
  • Many frail older adults with type 2 diabetes will have had their regimens intensified over preceding years when they were in better health, and many others will have been intensified or started on SUs or insulin more recently during acute hospital admissions, e.g., for infections, when their blood glucose levels might have been atypically high. In addition, in older frail adults who start to receive assistance in taking their medications, either following admittance to a care home or in another setting, treatment adherence that may previously have been poor can suddenly improve dramatically, leading to a fall in HbA1c levels
  • It should not be assumed that treatment regimens that have been intensified historically, or were initiated in hospitals should continue indefinitely. In the latter case, a return to pre-admission medications may be needed to avoid hypoglycaemia, although, in the case of longstanding symptomatic poor control, the escalated regimen may be appropriate if it is tolerated and the older adult is not severely frail
  • Primary care teams therefore need to consider each person with diabetes individually, but they should feel empowered to de-escalate a discharge regimen if appropriate
  • As frailty ensues, older adults lose adipose tissue, which, in turn, reduces underlying insulin resistance. As a result, much smaller doses of insulin are often sufficient to provide adequate and reproducible glycaemic control
  • Older adults with diabetes who have inadequate glycaemic control or recurrent hypoglycaemia on their current treatment regimen, who have had a significant change in circumstances, e.g., a move into a care home, or who are no longer be able to manage complex insulin therapy (may also apply to those with mild frailty whose cognitive or functional ability declines), may benefit from regimen simplification or de-escalation
  • It is recommended to follow the simple algorithm depicted in (Figure 1) for treatment simplification/de-escalation in the glycaemic management of older adults with type 2 diabetes
  • De-escalation of non-insulin glucose-lowering regimens can be achieved by either lowering the dose or discontinuing some medications
  • Insulin regimens can either be de-escalated by reduction of the dose or simplified by switching to more manageable regimens with lower risk of hypoglycaemia, for example from premix insulins to a basal insulin analogue with or without glucagon-like peptide 1 receptor agonist (GLP-1RA) or sodium-glucose cotransporter-2 inhibitor (SGLT2i)29,39
  • It is important to be mindful that SUs and GLP-1RAs raise endogenous insulin secretion, hence they decrease the unit dose requirement for exogenous insulin compared with insulin monotherapy. A sensible approach would be either to reduce the dose of SU when administered in combination with insulin or to discontinue SU treatment altogether, in favour of insulin monotherapy
  • Thiazolidinediones also increase sensitivity to insulin, so again, compensatory dose adjustments are required when these are used in combination with insulin. In a small proportion of individuals, stopping insulin suddenly can precipitate diabetic ketoacidosis, so insulin should be withdrawn slowly and response to each dose adjustment should be monitored, ideally within a month
  • Often during reviews of frail older adults, individuals will be identified with a low HbA1c (<48 mmol/mol; <6.5%). It should be considered that insulin resistance may have subsided sufficiently that no therapies are required. In this scenario, it is reasonable to discontinue all antihyperglycaemic agents and review control after 3 months, against an individualised HbA1c goal
  • Anti-hyperglycaemic therapies can work in synergy, hence the removal of one (even low-dose) component of a regimen can result in a dramatic rise in HbA1c (rebound hyperglycaemia). This highlights the importance of monitoring HbA1c and reviewing the individual if medication is de-escalated. HbA1c can rise sharply after stopping a SU, even if this has been taken for many years, so it may be appropriate to restart at a lower dose in such cases
  • Patients should be reviewed after each change in regimen (i.e. a 3-month review program with an HbA1c measurement after every withdrawal) to check that glycaemic control (and other risk factor management) is appropriate for the patient’s frailty category, and also to check whether frailty status has changed
  • In all cases it is important to explain to the individual (and relatives) that the reasons for de-escalation are concerned with improving symptoms, function and QoL, frailty status, and comorbidity. This is to avoid the misconception that de-escalation represents ‘giving up hope’ on the patient.

Conclusion

  • The management of older adults with type 2 diabetes is complicated by comorbidities, shortened life expectancy, and exaggerated consequences of adverse effects from treatment, such as hypoglycaemia
  • The assessment of frailty should be a routine component of a diabetes review for all older adults, and then glycaemic targets and therapeutic choices should be modified accordingly. After each intervention, frailty should be re-assessed, cognisant of the fact that frailty is a dynamic process and may be improved by the elimination of both hyper- and hypoglycaemia.

References

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  2. Clegg A, Young J, Iliffe S, Rikkert MO, et al. Frailty in elderly people. Lancet 2013; 381: 752–762.
  3. Sinclair AJ, Abdelhafiz AH, Forbes A, Munshi M. Evidence-based diabetes care for older people with Type 2 diabetes: a critical review. Diabet Med 2019; 36: 399–413.
  4. Clegg A, Bates C, Young J, et al. Development and validation of an electronic frailty index using routine primary care electronic health record data. Age Ageing 2016; 45: 353–360.
  5. Pernicova I, Korbonits M. Metformin–mode of action and clinical implications for diabetes and cancer. Nat Rev Endocrinol 2014; 10: 143–156. 
  6. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352: 854–865. 
  7. Aroda VR, Edelstein SL, Goldberg RB, et al. Long-term metformin use and vitamin B12 deficiency in the Diabetes Prevention Program Outcomes Study. J Clin Endocrinol Metab 2016; 101: 1754–1761. 
  8. Seino S, Sugawara K, Yokoi N, Takahashi H. ß-Cell signalling and insulin secretagogues: a path for improved diabetes therapy. Diabetes Obes Metab 2017; 19 Suppl 1: 22–29. 
  9. Sola D, Rossi L, Schianca GP, et al. Sulfonylureas and their use in clinical practice. Arch Med Sci 2015; 11: 840–848. 
  10. Strain WD, Lukashevich V, Kothny W, et al. Individualised treatment targets for elderly patients with type 2 diabetes using vildagliptin add-on or lone therapy (INTERVAL): a 24 week, randomised, double-blind, placebo-controlled study. Lancet 2013; 382: 409–416. 
  11. Buse JB, Wexler DJ, Tsapas A, et al. 2019 Update to: Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2020; 43: 487–493. 
  12. Sinha B, Ghosal S. Meta-analyses of the effects of DPP-4 inhibitors, SGLT2 inhibitors and GLP1 receptor analogues on cardiovascular death, myocardial infarction, stroke and hospitalization for heart failure. Diabetes Res Clin Pract 2019; 150: 8–16. 
  13. Toh S, Hampp C, Reichman ME, et al. Risk for hospitalized heart failure among new users of saxagliptin, sitagliptin, and other antihyperglycemic drugs: a retrospective cohort study. Ann Intern Med 2016; 164: 705–714. 
  14. Simes BC, MacGregor GG. Sodium-glucose cotransporter-2 (SGLT2) inhibitors: a clinician’s guide. Diabetes Metab Syndr Obes 2019; 12: 2125–2136. 
  15. Griffiths S, Strain WD. British Journal of Diabetes 2021; In press. 
  16. Scheen AJ. Effects of glucose-lowering agents on surrogate endpoints and hard clinical renal outcomes in patients with type 2 diabetes. Diabetes Metab 2019; 45: 110–121. 
  17. Davidson JA. SGLT2 inhibitors in patients with type 2 diabetes and renal disease: overview of current evidence. Postgrad Med 2019; 131: 251–260. 
  18. Strain WD, Holst AG, Rasmussen S, et al. Effects of liraglutide and semaglutide on stroke subtypes in patients with type 2 diabetes: a post hoc analysis of the LEADER, SUSTAIN 6 and PIONEER 6 trials (ePoster 398).  European Society of Cardiology Congress (ESC 365), 2020. 
  19. Milne N. How to use GLP-1 receptor agonist therapy safely and effectively. Diabetes & Primary Care 2019; 21: 45–46. 
  20. Novo Nordisk Limited. Rybelsus–summary of product characteristics. November 2020. www.medicines.org.uk/emc/product/11507/smpc#gref 
  21. Davidson MA, Mattison DR, Azoulay L, Krewski D. Thiazolidinedione drugs in the treatment of type 2 diabetes mellitus: past, present and future. Crit Rev Toxicol 2018; 48: 52–108. 
  22. de Jong M, van der Worp HB, van der Graaf Y, Visseren FLJ, et al. Pioglitazone and the secondary prevention of cardiovascular disease. A meta-analysis of randomized-controlled trials. Cardiovasc Diabetol 2017; 16: 134. 
  23. Ahmad J, Rafat D. HbA1c and iron deficiency: a review. Diabetes Metab Syndr 2013; 7: 118–122. 
  24. Zhu ZN, Jiang YF, Ding T. Risk of fracture with thiazolidinediones: an updated meta-analysis of randomized clinical trials. Bone 2014; 68: 115–123. 
  25. Billington EO, Grey A, Bolland MJ. The effect of thiazolidinediones on bone mineral density and bone turnover: systematic review and meta-analysis. Diabetologia 2015; 58: 2238–2246. 
  26. Schwartz AV, Chen H, Ambrosius WT, et al. Effects of TZD use and discontinuation on fracture rates in ACCORD Bone study. J Clin Endocrinol Metab 2015; 100: 4059–4066. 
  27. Lewis JD, Habel LA, Quesenberry CP, et al. Pioglitazone use and risk of bladder cancer and other common cancers in persons with diabetes. JAMA 2015; 314: 265–277. 
  28. Pettus J, Santos Cavaiola T, Tamborlane WV, Edelman S. The past, present, and future of basal insulins. Diabetes Metab Res Rev 2016; 32: 478–496. 
  29. Valentine V, Goldman J, Shubrook JH. Rationale for, initiation and titration of the basal insulin/GLP-1RA fixed-ratio combination products, IDegLira and IGlarLixi, for the management of type 2 diabetes. Diabetes Ther 2017; 8: 739–752. 
  30. Hope SV, Taylor PJ, Shields BM, et al. Are we missing hypoglycaemia? Elderly patients with insulin-treated diabetes present to primary care frequently with non-specific symptoms associated with hypoglycaemia. Prim Care Diabetes 2018; 12: 139–146.
  31. Freeman J. Management of hypoglycemia in older adults with type 2 diabetes. Postgrad Med 2019; 131: 241–250.
  32. Sinclair A, Dunning T, Rodriguez-Mañas L. Diabetes in older people: new insights and remaining challenges. Lancet Diabetes Endocrinol 2015; 3: 275–285.
  33. Abdelhafiz AH, Rodriguez-Manas L, Morley JE, Sinclair AJ. Hypoglycemia in older people - a less well recognized risk factor for frailty. Aging Dis 2015; 6: 156–167.
  34. Pathak RD, Schroeder EB, Seaquist ER, et al. Severe hypoglycemia requiring medical intervention in a large cohort of adults with diabetes receiving care in U.S. integrated health care delivery systems: 2005–2011. Diabetes Care 2016; 39: 363–370.
  35. Yun JS, Ko SH, Ko SH, et al. Cardiovascular disease predicts severe hypoglycemia in patients with type 2 diabetes. Diabetes Metab J 2015; 39: 498–506.
  36. Sinclair AJ, Bellary S. Preventing hypoglycaemia: an elusive quest. Lancet Diabetes Endocrinol 2016; 4: 635–636.
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  38. American Diabetes Association. 9. Pharmacologic approaches to glycemic treatment: standards of medical care in diabetes-2019. Diabetes Care 2019; 42: S90–S102.
  39. Min SH, Yoon JH, Hahn S, Cho YM. Comparison between SGLT2 inhibitors and DPP4 inhibitors added to insulin therapy in type 2 diabetes: a systematic review with indirect comparison meta-analysis. Diabetes Metab Res Rev 2017; 33.

 

About this management algorithm

Sponsor: Guidelines identified a need for clinical guidance in a specific area and approached Novo Nordisk for a sponsorship to support the development of a management algorithm. This algorithm was developed by Guidelines and Dr Strain. The content is independent of and not influenced by Novo Nordisk. The views and opinions expressed in this summary are not necessarily those of Novo Nordisk, or of Guidelines, its publisher, advisers, or advertisers. No part of this publication may be reproduced in any form without the permission of the publisher. 

Full guideline: Strain WD, Down S, Brown P, Puttanna A, and Sinclair AJ. Diabetes and Frailty: Guidance on the management of older adults with type 2 diabetes. UK expert consensus statement. Diabetes Ther 2021 (in press)

Date of preparation: February 2021