How Should We Be Treating Seniors with Diabetes?
I was recently scanning the news and came across an article in the New York Times titled “Some Older Patients Are Treated Not Wisely, but Too Much,” and needless to say was immediately intrigued. The article raises important concerns about the overtreatment of people with diabetes; however, it fails to address the growing number of methods designed to minimize these very risks that are so very important as this epidemic expands beyond what anyone imagined.
It is true that most mealtime insulins, as well as sulfonylureas, come with a meaningful risk of hypoglycemia. As a person with diabetes, I welcome the chance to mitigate this risk. However, in just the past decade, many new diabetes drug classes now exist with virtually no risk of low blood sugars (incretins, SGLT-2 inhibitors). And more importantly, at least one of these drugs, Jardiance (empagliflozin), recently showed reduced cardiovascular risk in high-risk elderly people with type 2 diabetes.
We need to move away from a "one-size-fits-all" approach. This piece generalizes that a more relaxed approach could work for all senior patients. In response to this, I echo the ADA/EASD joint recommendation: “Individualization of treatment is the cornerstone of success.” Therapies that are easier to use (resulting in less hypoglycemia and weight gain) and easier to prescribe should be considered – as, undoubtedly, should recommendations to relax goals where it makes sense to do so.
Implying that an A1c of 8% produces the same benefits as an A1c of 6.5% understates the complications that higher blood sugars cause. These include blindness, renal failure, and severe nerve damage, along with cardiovascular disease and stroke. According to the landmark UKPDS trial, each percentage point reduction in A1c (e.g., 9 to 8%) correlates with a 35% reduction in microvascular complications (blindness, kidney disease, nerve damage), a 25% reduction in diabetes-related deaths, and an 18% reduction in combined fatal and non-fatal heart attacks.
When I turn 65, it would be incredibly disheartening if my doctor simply encouraged an A1c of 8% - especially since I may well then only achieve an A1c of 9%. It's a slippery slope! We should aim to do everything in our power to get people in good diabetes control. For some people that may mean a higher A1c, but that shouldn't be generalized across all patients. Instead of going for a "safe" A1c, why not just encourage safer medicines? With nearly 50% of the US diabetes population not at controlled glycemic targets, broadly encouraging higher A1cs is not the direction in which we should be heading.