Memorias Conferencia Científica Anual sobre Síndrome Metabólico 2017 - Programa Científico Manejo de la diabetes en el anciano Dr. Guillermo E. Umpierrez Professor of Medicine in the Division of Endocrinology at Emory University School of Medicine, Section Head, Diabetes and Endocrinology. USA. Editor en Jefe del BJM Open Diabetes Research and Care.

1. Guillermo Umpierrez, MD, CDE. FACE,Guillermo Umpierrez, MD, CDE. FACE,
FACPFACP
Professor of MedicineProfessor of Medicine
Division of EndocrinologyDivision of Endocrinology
Emory University SOMEmory University SOM
Atlanta, Georgia, USAAtlanta, Georgia, USA
Manejo de la Diabetes en elManejo de la Diabetes en el
AncianoAnciano

2. External Industry
Relationships *
Company Name(s) Role
Equity, stock, or
options in biomedical
industry companies or
publishers
BMJ Open Diabetes
Research & Care
AACE
Editor-in-Chief
Board of Directors
Industry funds to
Emory University for
my research
Merck,
Sanofi,
Novo Nordisk
Boehringer Ingelhein
Astra Zeneca
Investigator-Initiated
Research Projects
Industry
Advisory/Consultant
activities
Dr. Guillermo Umpierrez,
Personal/Professional Financial Relationships with Industry
February 2017

3. Educational ObjectivesEducational Objectives
 1. Scope of the problem and burden of1. Scope of the problem and burden of
complications in the elderly populationcomplications in the elderly population
 2. Importance of adequate and individualized2. Importance of adequate and individualized
glucose control in this populationglucose control in this population
 Recent guideline recommendationsRecent guideline recommendations
 3. Methods for achieving glucose control in3. Methods for achieving glucose control in
elderly patientselderly patients

4. Definition of theDefinition of the “Elderly” Patient?“Elderly” Patient?
No general agreement on the age atNo general agreement on the age at
which a person becomes elderlywhich a person becomes elderly
Most developed countries: ≥65 yoMost developed countries: ≥65 yo
Medicare eligibility: ≥ 65 yoMedicare eligibility: ≥ 65 yo
United Nations: ≥ 60 yoUnited Nations: ≥ 60 yo
WHO study in Africa: ≥ 50 yoWHO study in Africa: ≥ 50 yo
http://www.who.int/healthinfo/survey/ageingdefnolder/en/; National Institute of Aging: Minimum Data Set
Project Directory of Research on Adult Health and Ageing in Africa: 1995-2003;.
Speaker definition: age= 10 years older than the eldest
in this room

5. Exponential Growth of Adults ≥ 65 in the USExponential Growth of Adults ≥ 65 in the US
www.aoa.gov/Aging_Statistics/future_growth/future_growth.aspx#age
www.cdc.gov/diabetes/statistics/incidence/fig5.htm.
1 out of every 5
•“By 2030, it is estimated that there will be 8.3 billion people on this planet, with 13% over the age
of 65 years—the fastest-growing age group”

6. Global Population Increase of PeopleGlobal Population Increase of People
Aged ≥ 65 years: 1950-2050Aged ≥ 65 years: 1950-2050
Source: United Nations. World Population Prospects: The 2010 Revision.

7. People are Living LongerPeople are Living Longer
US Population of Adults 55+,
(Millions)
Between 2010-2028, 8000 baby
boomers will turn 65+
CDC 2010 data; http://www.aarp.org/personal-growth/transitions/boomers_65
Average Life Expectancy
76.5

8. Life expectancyLife expectancy
NYT

9. Age at Diagnosis of Incident Cases ofAge at Diagnosis of Incident Cases of
Diabetes, Aged 18–79 Years, US, 2011Diabetes, Aged 18–79 Years, US, 2011
Data Source: Centers for Disease Control and Prevention (CDC), National Center for Health Statistics,
Division of Health Interview Statistics, data from the National Health Interview Survey, 2011.
27%
21%

10. Prevalent Comormidities among
older patients with T2DM
% of population with
specific comorbidities
Nielfeld MR Diabetes Care; 2003; 26:1344-1349

11. DM in the Elderly: Outpatient ManagementDM in the Elderly: Outpatient Management
ADA & AGS Consensus . JAGS 2012: 1-15
Diab Care,36: Suppl 1, 2013:S11-S-66
Garber et al. Endocrine Practice, in press 2013

12. Goals of DM managementGoals of DM management
 Control hyperglycemiaControl hyperglycemia
 Avoidance of hypoglycemiaAvoidance of hypoglycemia
 Prevent, manage, and treatPrevent, manage, and treat
macrovascular and microvascularmacrovascular and microvascular
complicationscomplications
 Maintain or improve overall healthMaintain or improve overall health
statusstatus

13. Lowering
HgA1c
Lowering
HgA1c
Preventing
Hypoglycemia
Preventing
Hypoglycemia
Glycemic Management of Type 2
Diabetes
Individualized Algorithm
Treatment Goals

14. Common Issues Affecting Older PatientsCommon Issues Affecting Older Patients
Increased comorbiditiesIncreased comorbidities
 High burden of CKD and CVDHigh burden of CKD and CVD
 ~25-30 % of those > 85yo have dementia~25-30 % of those > 85yo have dementia
Decreasing visionDecreasing vision
Poor dentition and decreased appetitePoor dentition and decreased appetite
PolypharmacyPolypharmacy
Limited physical activity/disabilityLimited physical activity/disability
Limited financial resourcesLimited financial resources

15. 2003/2013 AGS Guidelines for the Older2003/2013 AGS Guidelines for the Older
Person with Diabetes MellitusPerson with Diabetes Mellitus
 Focus on individualizing care and educationFocus on individualizing care and education
 Prevention and management of cardiovascularPrevention and management of cardiovascular
risk factorsrisk factors
 Prevention and management of microvascularPrevention and management of microvascular
complications via glycemic controlcomplications via glycemic control
 Screen for and treat geriatric syndromes thatScreen for and treat geriatric syndromes that
are more common in older adults with DMare more common in older adults with DM
CHF/American Geriatrics Society (AGS) Panel . Guidelines for Improving the Care of the Older
Person with Diabetes Mellitus. J Am Geri Soc 2003; 51:S265-S280

16. American Geriatric Society:American Geriatric Society:
A1c Recommendations 2013 for 65+A1c Recommendations 2013 for 65+
 7.5 - 8%7.5 - 8% in general for the older adultsin general for the older adults
 7% - 7.5%7% - 7.5% may be appropriate if it can be safelymay be appropriate if it can be safely
achieved in healthy older adults with fewachieved in healthy older adults with few
comorbidities and good functional statuscomorbidities and good functional status
 8% - 9%8% - 9% is appropriate for older adults withis appropriate for older adults with
multiple comorbidities, poor health, and limitedmultiple comorbidities, poor health, and limited
life expectancy (IIA)life expectancy (IIA)
 Potential harm in lowering A1C to < 6.5% in olderPotential harm in lowering A1C to < 6.5% in older
adults with type 2 DM (IIA)adults with type 2 DM (IIA)
CHF/American Geriatrics Society (AGS) Panel . Guidelines for Improving the Care of the Older
Person with Diabetes Mellitus. J Am Geri Soc 2013; 51:S265-S280

17. ADA, Glycemic Targets in Older AdultsADA, Glycemic Targets in Older Adults
Standards of care. Older adults. ADA.Standards of care. Older adults. ADA. Diabetes CareDiabetes Care. 2016;(suppl 1):S83.. 2016;(suppl 1):S83.
Target Rationale Fasting Bedtime
Blood
Pressure
Lipids
A1C
< 7.5%
Longer remaining
life expectancy
90-130 90-150 <140/90
Statin unless
contraindicated
or not tolerated
A1C
< 8%
Intermediate
remaining life
expectancy, high
treatment burden,
hypoglycemia,
vulnerability, fall risk
90-150 100-180 <140/90
Statin unless
contraindicated
or not tolerated
A1C
<8.5%
Limited remaining
life expectancy
makes benefit
uncertain
100-180 110-200 <150/90
Consider
likelihood of
benefit with
statin (secondary
prevention more
so than primary)

18. N = 652,378 patients receiving insulin or sulfonylurea. The denominator population: patients 75
years or older; serum creatinine level, 2.0mg/dL; or diagnosis of cognitive impairment or
dementia. A,B,C, outliers.
Tseng CL, et al. JAMA Intern Med. 2014;174:259-268.
http://www.va.gov/health/NewsFeatures/20111115a.asp.
Diabetes May Be Over-treatedDiabetes May Be Over-treated
Among Older AdultsAmong Older Adults
• About 25% of patients in the VA system have diabetes
VA Healthcare System
6.5 - 7
6.0 - <6.5
<6

19. Longitudinal Trends in Hospital Admission for
Hyperglycemia and Hypoglycemia in Older Adults
Hypoglycemia Hyperglycemia
Lipska KJ, et al. JAMA Intern Med.
2014;174:1116-1124.
• Currently, hypoglycemia accounts for more hospital admissions than hyperglycemia
• Hypoglycemia risk is greatest in patients aged ≥ 75 years
0
50
100
150
200
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
HospitalAdmissions
per1000,000person-years
Year
65-74 y 75-84 y ≥ 85 y
0
50
100
150
200
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
HospitalAdmissions
per1000,000person-years
Year
65-74 y 75-84 y ≥ 85 y

20. Lifestyle changes
Maintenance of Glycemic Control with OralMaintenance of Glycemic Control with Oral
Antidiabetic Agents in Elderly PopulationsAntidiabetic Agents in Elderly Populations
Metformin DPP4-I
SGLT2-I GLP1-
RAAcarbose
Avoid/Caution:
1.Sulfonylures due to hypoglycemia, CVD?
2.TZDs due to risk of osteoporosis, fractures and
HF

21. Efficacy of metformin in elderly and old-elderly
(>75 yrs) vs. non-elderly (<65 yrs) patients.
Data are mean SEM.
*P < 0.05;
**P < 0.01;
***P < 0.001 vs. baseline.
Metformin in elderly
patients with T2D is
not different from
that in non-elderly
patients,
Ito et al. Geriatr Gerontol Int 2011; 11: 55–62

22. SulfonylureasSulfonylureas
Used by 30-45% of type 2 diabeticsUsed by 30-45% of type 2 diabetics
Those with longer half-life have increased risk ofThose with longer half-life have increased risk of
hypoglycemiahypoglycemia
• GlyburideGlyburide
Risk factors of hypoglycemia with sulfonylureasRisk factors of hypoglycemia with sulfonylureas
• Age > 60, disability, poor nutrition, polypharmacyAge > 60, disability, poor nutrition, polypharmacy
• Drugs which potentiate their actionDrugs which potentiate their action

23. Relative Risk for experiencing hypoglycemia:Relative Risk for experiencing hypoglycemia:
Glyburide vs other secretagoguesGlyburide vs other secretagogues
Glyburide was associated with a 52% greater risk of experiencing at least one episode
of hypoglycemia compared with other secretagogues (RR 1.52 [95% CI 1.21–1.92]) and
with 83% greater risk compared with other sulfonylureas (1.83 [1.35–2.49]).
Gangji et al Diabetes Care 30:389–394, 2007

24. Hypoglycemia and Annualized Mortality
Rates Within Treatment Groups: ACCORD
None
>1
0
1
2
3
4
5
Standard
Intensive
1.0 1.3
4.9
2.9
Percent(%)perYear
Requiring Medical Assistance
(HMA)‡
None
≥1
0
1
2
3
4
5
Standard
Intensive
1.0 1.2
3.7
2.8
Percent(%)perYear
Requiring Any Assistance, Medical
orNon-medical (HA)†
Adapted from: Bonds DE, et al. BMJ. 2010 Jan 8;340:b4909. doi: 10.1136/ bmj.b4909.
n=201/
16315*
n=53/
1924*
n=176/
17297*
n=21/
564*
n=220/
17031*
n=34/
1208*
n=180/
17516*
n=17/
345*
Mortality Rate (n=451 deaths)
* Person-years
† p = .076 forinteraction between history of hypoglycemia requiring any assistance and glycemia intervention
‡ p = .009 forinteraction between history of hypoglycemia requiring medical assistance and glycemia intervention

25. Severe Hypoglycemia in 3 Outcome Trials of
Intensive Glucose Control in Type 2 Diabetes
0
5
10
15
20
25
VADT ACCORD ADVANCE
%Patientswithatleastonesevere
hypoglycemiceventduringthetrial Intensive Control
Standard Control
p < .001
p < .001
p < .001
Adapted from:
1. The Action to Control CardiovascularRisk in Diabetes Study Group. N EnglJMed. 2008;358:2545-2559.
2. The ADVANCECollaborative Group. N EnglJMed. 2008;358:2560-2572.
3. Duckworth W, et al.. N EnglJMed. 2009;360:129-139.

26. All-Cause Mortality following Treatment with
Metformin or Glyburide in Patients with T2D
Glyburide
Metformin
Reza et al. Arch Iranian Medi, 20 (3):141-146, 2017 141
717 patients with T2D (271 on glyburide, 446 on
metformin monotherapy, 3 year F/U.
All cause mortality 6.3% in glyburide and 1.6% in
metfomin group, p<0.001

27. CGM Can Reveal Unsuspected Hypo- and Hyperglycemia
in Well-Controlled Older Adults With T2DM
• Study participants
! N = 25
! SU ± MET, no insulin
! Age: 73.9 ± 4.4 y
! Duration of DM: 11 ± 7 y
! Baseline A1C: 6.2 ± 0.8%
! FPG: 139 ± 40 mg/dL
• Hypoglycemia
! Overall, 20 of 25 patients
had hypoglycemia
! 14 of 25 had BG ≤ 40 mg/dL
! NONE of the patients
reported hypoglycemia
Hay LC, et al. Diabetes Technol Ther. 2003;5:19-26.
Designnote:Scalewillbeconvertedtomg/dLif
selectedforpresentation
Typical 24-h CGM Tracing

28. Placebo-corrected change from baseline in HbA1c - Monotherapy
Comparative Efficacies of DPP-4sComparative Efficacies of DPP-4s
-0.1
-0.3
-0.2
-0.4
-0.8
-0.5
-0.6
-0.7
-0.9
-1.0
-1.1
-1.2
ΔHbA1c(%) Alogliptin1
12.5mg 25mg
7.9% 7.9%
Linagliptin2
5mg 5mg
8.1% 8.0%
Saxagliptin2
5mg 5mg
7-10% 8.0%
Sitagliptin2
100mg 100mg
8.0% 8.0%
Vildagliptin3
50mg BID 50mg
8.6% 8.4%
The current DPP-4s have comparative efficacy
1. DeFronzo R, et al. Diabetes Care 2008;31:2315-2317.
2. Linagliptin Prescribing Information.
3. Saxagliptin Prescribing Information.
4. Sitagliptin Prescribing Information.
5. Vildagliptin Summary of Product Characteristics.
-0.56
-0.59 -0.6
-0.7
-0.4
-0.6 -0.6
-0.8
-0.5
-0.7

29. Saxagliptin compared with GlimepirideSaxagliptin compared with Glimepiride
in elderly patients with type 2 diabetesin elderly patients with type 2 diabetes
Schernthaner et al. Diabetes, Obesity and Metabolism 17: 630–638, 2015

30. Linagliptin Shows Rates of HypoglycemiaLinagliptin Shows Rates of Hypoglycemia
Similar to PlaceboSimilar to Placebo
Yki-Järvinen H, et al. Diabetes Care. 2013;36:3875-3881.
Investigator-defined hypoglycemia AEs at week 24 by category

31. The durability of sitagliptin in elderlyThe durability of sitagliptin in elderly
patients with T2Dpatients with T2D
Ching-Jung Hsieh et al. Clin Interv Aging. 2014; 9: 1905–1911

32. Benefits and Advantages of DPP4-iBenefits and Advantages of DPP4-i
Therapy in Elderly Patients with T2DTherapy in Elderly Patients with T2D
 Lower HbA1c ~0.4%–0.9% from baselineLower HbA1c ~0.4%–0.9% from baseline
 Weight neutralWeight neutral
 Once-daily oral therapyOnce-daily oral therapy
 Low-risk of hypoglycemia (as monotherapy)Low-risk of hypoglycemia (as monotherapy)
 Minimal GI side effectsMinimal GI side effects
 Approved as monotherapy or combinationApproved as monotherapy or combination
therapytherapy

33. Thiazolidinediones:Thiazolidinediones:
Rosiglitazone - PioglitazoneRosiglitazone - Pioglitazone
Mechanism of action: Enhance tissue response
to insulin; decrease
hepatic glucose production
Therapeutic efficacy: Decrease HbA1c 0.8% - 2.6%
Recommended dosing: Pioglitazone: 15-45 mg QD
Side effects: Edema, weight gain, CHF, MI
osteopenia, bladder cancer?
Contraindications: Known hypersensitivity; pre-
existing liver disease, type 1
diabetes, DKA

34. SGLT-2 Inhibitor – kidney is target organ
Renal glucose reabsorption
Glucose
Proximal tubule
S1 segment
SGLT2
~90% glucose
reabsorption
SGLT-1
~10% glucose
reabsorption
S3
segment
Collecting
ducts

35. Perspectives on SGLT2 InhibitionPerspectives on SGLT2 Inhibition
AdvantagesAdvantages
 Improved glycemicImproved glycemic
controlcontrol
 Weight lossWeight loss
 Low risk ofLow risk of
hypoglycemiahypoglycemia
 Blood pressureBlood pressure
loweringlowering
 Reduce cardiovascularReduce cardiovascular
events and mortalityevents and mortality
Concerns
• Polyuria
• Electrolyte
disturbances
• Urinary tract infections
• Fungal genital
infections
• DKA
• Bone fractures

36. Older Adults and Insulin TherapyOlder Adults and Insulin Therapy
 The increased risk of hypoglycemia due toThe increased risk of hypoglycemia due to
antidiabetic agents is a major concern whenantidiabetic agents is a major concern when
considering treatment options in older adultsconsidering treatment options in older adults
 Insulin is the antidiabetic agent most oftenInsulin is the antidiabetic agent most often
responsible for hypoglycemiaresponsible for hypoglycemia
Characteristics Desired in Insulin RegimensCharacteristics Desired in Insulin Regimens
 Lower risk of hypoglycemiaLower risk of hypoglycemia
 Once daily dosingOnce daily dosing
 Easy to administerEasy to administer
Budnitz DS, et al. N Engl J Med. 2011;365:2002-2012.

37. Older Adults Have the Highest Risk ofOlder Adults Have the Highest Risk of
Insulin-Related Hypoglycemia andInsulin-Related Hypoglycemia and
Errors Leading to ED VisitsErrors Leading to ED Visits
National estimate of 97,648 insulin-related hypoglycemia and insulin errors derived from
8100 cases reported in CDC databases during 2007-2011.
1. Geller AI, et al. JAMA Intern Med. 2014;174:678-686.
2. Budnitz DS, et al. N Engl J Med. 2011;365:2002-2012.
 Patients aged ≥ 80 years have the highest risk of ED visits forPatients aged ≥ 80 years have the highest risk of ED visits for
hypoglycemiahypoglycemia11
 94.6% of hospitalizations related to antihyperglycemic agents in94.6% of hospitalizations related to antihyperglycemic agents in
older adults are for hypoglycemiaolder adults are for hypoglycemia22

38. STEP IT UP A Bit (Pens vs Needles)STEP IT UP A Bit (Pens vs Needles)
Study TypeStudy Type:: Prospective, randomized,Prospective, randomized,
cross-over trialcross-over trial
Aim:Aim: Compare efficacy, patient satisfaction,Compare efficacy, patient satisfaction,
and safety of an add-on basal insulin viaand safety of an add-on basal insulin via
insulin pen vs by vial/syringe in elderly withinsulin pen vs by vial/syringe in elderly with
diabetes.diabetes.
Study SiteStudy Site: Grady Memorial Hospital: Grady Memorial Hospital
Patient PopulationPatient Population : 56 subjects ≥60 years: 56 subjects ≥60 years
old on diet ± OADs w/ A1c >7%old on diet ± OADs w/ A1c >7%
Newton, Ivie, Smiley, et al. ADA Scientific Sessions 2013, Abstract Poster 804; NCT 01240200

39. Effects of Pens vs Syringes on GlycemicEffects of Pens vs Syringes on Glycemic
ControlControl
Newton, Ivie, Smiley, et al. ADA Scientific Sessions 2013, Abstract Poster 804
Insulin initiation improves glycemic control in older adults

40. Insulin Pens Are Associated With Lower Risks of DosingInsulin Pens Are Associated With Lower Risks of Dosing
Errors and Hypoglycemia Than Vial-and-Syringe InsulinErrors and Hypoglycemia Than Vial-and-Syringe Insulin
DeliveryDelivery
Dosing Errors vs Delivery DeviceDosing Errors vs Delivery Device11
Hypoglycemia vs Delivery DeviceHypoglycemia vs Delivery Device11
Hypoglycemia, BG < 70 mg/dL; a
Events measured per person.
1. Newton C, et al. AACE Annual Meeting. 2013 [abstract 271].
2. Budnitz DS, et al. N Engl J Med. 2011;365:2002-2012.
• Insulin is implicated in 67% of all adverse drug event–related hospitalizations in older
adults2
• With vials and syringes, dosing errors are more common and lead to more hypoglycemic
events (1.5 vs 0.4 events, P = .01)1,a
• With pens, dosing errors did not significantly increase hypoglycemic events 1,a
P < .01
P < .05

41. And what about insulin in the nursingAnd what about insulin in the nursing
home setting?home setting?
 More and more people with diabetes areMore and more people with diabetes are
living to older agesliving to older ages
 Approximately 1 in 4 NH residents hasApproximately 1 in 4 NH residents has
diabetes (24-35%)diabetes (24-35%)
 2007 study showed that only 38% met BG2007 study showed that only 38% met BG
goals and 67% reached A1c goals while in agoals and 67% reached A1c goals while in a
long-term care (LTC) facilitieslong-term care (LTC) facilities
 Few studies have reported on the quality ofFew studies have reported on the quality of
DM care and glycemic control adjusted forDM care and glycemic control adjusted for
medication use in a LTCmedication use in a LTC
Travis S, etal. 2004 J Am Med Dir Assoc 5:320-327; Holt, et al. Diabetes Care 30:1454–1458, 2007

42. Prevalence of Diabetes andPrevalence of Diabetes and
Glycemic Control in Long-Term CareGlycemic Control in Long-Term Care
ResidentsResidents
Newton et al. JAMDA 14 (2013) 842e846
NPH
Premixed
16%
No Drug Rx
10%
SSI
25%
Basal
+/- SSI
24%
OAD
+/- SSI

43. Pasquel et al. BMJ Open Diabetes Research and Care 2015
Diabetes in long-term care facilitiesDiabetes in long-term care facilities

44. Diabetes Care in Elderly PatientsDiabetes Care in Elderly Patients
Admitted to Long-Term Care FacilitiesAdmitted to Long-Term Care Facilities
 Study TypeStudy Type:: Pilot, RCT trialPilot, RCT trial
 Aim:Aim: Determine differences in glycemic control withDetermine differences in glycemic control with
Basal insulin vs versus oral antidiabetic agents inBasal insulin vs versus oral antidiabetic agents in
nursing home patients with type 2 diabetesnursing home patients with type 2 diabetes
 Patient PopulationPatient Population : 150 diabetic subjects treated: 150 diabetic subjects treated
with diet and/or OADs with BG >180 mg/dl or A1Cwith diet and/or OADs with BG >180 mg/dl or A1C
>7.5%>7.5%
Pasquel et al. BMJ Open Diabetes Research and Care 2015

45. Mean daily glucose levels in patients withMean daily glucose levels in patients with
T2D treated with basal insulin and oralT2D treated with basal insulin and oral
agents in long-term care facilitiesagents in long-term care facilities
Pasquel et al, BMJ Diabetes Care & Research 2015

46. Frequency in hypoglycemia in nursing home
patients treated with basal insulin or OADs
Pasquel et al, BMJ Diabetes Care & Research 2015

47. Randomized Controlled StudyRandomized Controlled Study
Comparing Linagliptin (± Metformin) andComparing Linagliptin (± Metformin) and
Glargine (± Metformin) in elderly patientsGlargine (± Metformin) in elderly patients
in LTCin LTC
 Aim:Aim: Differences in glycemic control with BasalDifferences in glycemic control with Basal
(glargine) insulin(glargine) insulin (± Metformin)(± Metformin) vs linagliptinvs linagliptin (±(±
Metformin)Metformin) in nursing home patients with diabetesin nursing home patients with diabetes
 Study SitesStudy Sites: Emory, Grady and AtlantaVAMC: Emory, Grady and AtlantaVAMC
Affiliated LTC facilitiesAffiliated LTC facilities
 Patient PopulationPatient Population:T2D treated with diet and/or:T2D treated with diet and/or
OADs or Low-dose insulin (TDD < 0.1 U/Kg) withOADs or Low-dose insulin (TDD < 0.1 U/Kg) with
BG >180 mg/dl and/or A1C >7.5%BG >180 mg/dl and/or A1C >7.5%
Umpierrez et al, NCT01131052

48. Linagliptin versus Glargine in LTC
LTC residents with DM2
on diet, OADs, low-dose insulin
BG > 180 mg/dL and A1C > 7.5%
Glargine
(± metformin)
n= 75
Linagliptin
(± metformin)
n= 75
Umpierrez et al. ADA Scientific Meeting, San Diego, 2017

49. Glargine vs. Linagliptin in LTC:Glargine vs. Linagliptin in LTC:
Mean Weekly BG During TreatmentMean Weekly BG During Treatment
Basal Linagliptin p
Mean daily BG, mg/dL 157±36 146±34 0.06
Umpierrez et al. ADA Scientific Meeting, San Diego, 2017

50. BG <70 BG <54 BG <40
0
10
20
30
40
Frequency of Hypoglycemia According to Treatment GroupHypoglycemia(%)
Glargine Linagliptin
p<0.001
p=0.06
p=0.5
Glargine vs. Linagliptin in LTC:Glargine vs. Linagliptin in LTC:
Mean Weekly BG During TreatmentMean Weekly BG During Treatment
Umpierrez et al. ADA Scientific Meeting, San Diego, 2017

51.  Treatment with linagliptin resulted in equivalent
glycemic control and in lower rates of hypoglycemia
compared to insulin glargine.
 Our results indicate that an initial treatment with
linagliptin (± metformin) should be preferred over the
use of basal insulin (± metformin) in LTC residents
with T2D.
 The use of antidiabetic agents associated with low-
rate of hypoglycemia should be preferred over agents
associated with hypoglycemia (insulin and insulin
secretagogues).
Linagliptin (± Metformin) and Glargine (± Metformin) inLinagliptin (± Metformin) and Glargine (± Metformin) in
LTC: Summary & ConclusionLTC: Summary & Conclusion

52. Management of Hyperglycemia in Type 2Management of Hyperglycemia in Type 2
Diabetes: A Patient-Centered ApproachDiabetes: A Patient-Centered Approach
Position Statement of the American Diabetes Association (ADA) andPosition Statement of the American Diabetes Association (ADA) and
the European Association for the Study of Diabetes (EASD)the European Association for the Study of Diabetes (EASD)
Diabetes Care 2012;35:1364–1379
Diabetologia 2012;55:1577–1596
SUSU TZD SGLT2 GLP1DPP4 Insulin

53. Glycemic Treatment Goals in Elderly Subjects withGlycemic Treatment Goals in Elderly Subjects with
Diabetes.Diabetes. SummarySummary
 Patients ≥ 65 years of age represent the largest growingPatients ≥ 65 years of age represent the largest growing
population with diabetespopulation with diabetes
 The life expectancy is projected to increase and thisThe life expectancy is projected to increase and this
population is at greater risk of having diabeticpopulation is at greater risk of having diabetic
complicationscomplications
 Individualize glycemic targets and educateIndividualize glycemic targets and educate
 Target A1C < 7% for the healthier, older patientTarget A1C < 7% for the healthier, older patient
 Target 7-8 for the older patient with multipleTarget 7-8 for the older patient with multiple
comorbidities, poor health,comorbidities, poor health, ↑↑ risk of hypoglycemia andrisk of hypoglycemia and
limited life expectancylimited life expectancy
 More research is needed! Safest and most effectiveMore research is needed! Safest and most effective
regimen?regimen?

54. Glycemic Targets in Older Adults, ADAGlycemic Targets in Older Adults, ADA
Standards of care. Older adults. ADA.Standards of care. Older adults. ADA. Diabetes CareDiabetes Care. 2016;(suppl 1):S83.. 2016;(suppl 1):S83.
Target Rationale Fasting Bedtime
Blood
Pressure
Lipids
A1C
< 7.5%
Longer remaining
life expectancy
90-130 90-150 <140/90
Statin unless
contraindicated
or not tolerated
A1C
< 8%
Intermediate
remaining life
expectancy, high
treatment burden,
hypoglycemia,
vulnerability, fall risk
90-150 100-180 <140/90
Statin unless
contraindicated
or not tolerated
A1C
<8.5%
Limited remaining
life expectancy
makes benefit
uncertain
100-180 110-200 <150/90
Consider
likelihood of
benefit with
statin (secondary
prevention more
so than primary)

55. Patient Preference ORAL Agents in thePatient Preference ORAL Agents in the
Elderly: Hypoglycemia AvoidanceElderly: Hypoglycemia Avoidance
metformin
DPP4
inhibitor
TZD
α
-glucosidase
inhibitor
sulfonylurea
glinide
GLP1
Analogs
Insulin
SGLT2-I
Preferred Not PreferredCaution

56. ConclusionsConclusions
Individualize treatment regimenIndividualize treatment regimen
State appropriate glycemic goalsState appropriate glycemic goals
Treat cardiovascular risksTreat cardiovascular risks
Reduce medicationsReduce medications
Reduce fall riskReduce fall risk
Education and supportEducation and support
Watch for associated conditionsWatch for associated conditions
 Depression, urinary incontinence, painDepression, urinary incontinence, pain

57. Guillermo E. Umpierrez, MDGuillermo E. Umpierrez, MD
geumpie@emory.edugeumpie@emory.edu
Thank you!Thank you!

58. Guillermo Umpierrez, MD, CDE. FACE,Guillermo Umpierrez, MD, CDE. FACE,
FACPFACP
Professor of MedicineProfessor of Medicine
Division of EndocrinologyDivision of Endocrinology
Emory University SOMEmory University SOM
Atlanta, Georgia, USAAtlanta, Georgia, USA
Management of Elderly SubjectsManagement of Elderly Subjects
with Diabeteswith Diabetes