Comprehensive management diabetes in the elderly slide.pptx

diabetes in the elderly is a clinical situation that needs comprehensive management

1. Comprehensive Management Of Elderly Diabetes Patients in New Era Dr. Nanang Miftah Fajari , SpPD KEMD Divisi Endocrinology Metabolik dan Diabetes

2. Case Wanita 68 th , terdiagnosa DM sejak 10 th y.l Saat ini sering mengeluh sering merasa gemetaran bila habis minum obat diabetes. 2 minggu y.l penderita dibawa ke IRD karena ditemukan tidak sadar di kamar mandi. Saat di UGD gula darahnya 34 mg/dl. Selain itu penderita juga mengeluh matanya kabur dan sering sesak bila berjalan jauh Tekanan darah 160/100. Penderita hidup sendiri dan sering lupa /salah dalam minum obat Obat diabetes yang diminum saat ini gliclazid 1x1 tab, metformin 3x500 mg, dan Pioglitazone 1x30 mg Lab : Gd Puasa : 158 mg/dL GD 2 jam PP : 230 mg/dL A1c: 8,8% eGFR 40 Prot uri : +1 ECG : OMI inferior Ro Thorax : CTR >60% Funduscopy : NPDR

3. DM type 2 in elderly, Hypertension, CAD, HF St C, CKD. St 3, dementia DM type 2 in elderly, Hypertension, CAD, CKD. St 3, Retinopathy DM type 2 in elderly, Hypertension, HF St C, CKD. St 3, Retinopathy DM type 2 in elderly, Hypertension, CAD, HF St C, CKD. St 3, Retinopathy, History of Hypoglycemia, dementia Apa yang menjadi problem pada pasien tersebut ?

4. Berapa Rekomendasi Target Kendali Gula Darah? A1c < 6,5 % A1C < 7 A1C < 7,5 A1C antara 7,5 – 8 % A1C antara 7,5 – 8,5%

5. Apa Pilihan anda untuk Pengobatan DM pada pasien ini ? Lanjutkan terapi yang ada ( Gliclazid , Metformin, pioglitazone ) dengan penyesuaian dosis . Stop Gliclazid , sedang metformin dan pioglitazone lanjut . Stop Gliclazid dan Metformin, sedang pioglitazone lanjut . Ganti semua obat

6. Apa pilihan obat anti diabetes yang tepat pada pasien dengan co morbid di atas ? GLP 1 RA SGLT2 – inhibitor Insulin DPP4 inhibitor

7. Elderly Patients…. (> 65 years to 75 years ) 1 More likely to have an increased number of comorbid conditions ( eg , frailty, dementia, depression, urinary incontinence) 2 Age-related changes : impair vision and kidney function reduce physical strength and stamina increase sensitivity to the side effects of medications More likely to have hypoglycemia unawareness and recurrent hypoglycemia . Cognitive decline may impair patients’ understanding of and motivation for proper self-care. Associated with polypharmacy, increasing the risk of drug adverse events and potentially drug interactions. 3 Pharm Pract (Granada). 2014 Oct-Dec; 12(4): 489 https://www.aace.com/disease-state-resources/diabetes/depth-information/glycemic-management-type-2-diabetes Can J Diabetes 42 (2018) S283–S295

8. Most common clinical conditions associated with aging Longo M, Bellastella G, Maiorino MI,Meier JJ, Esposito K and Giugliano D, (2019) Diabetes and Aging: From Treatment Goals to Pharmacologic Therapy. Front. Endocrinol. 10:45.

9. Diabetes in Elderly : Statistic View Le Roith D et al. J Clin Endocrinol Metab 104: 1520–1574, 2019

10. Diabetes in Elderly : Statistic View Le Roith D et al. J Clin Endocrinol Metab 104: 1520–1574, 2019

11. Diabetes in Elderly : Statistic View Le Roith D et al. J Clin Endocrinol Metab 104: 1520–1574, 2019

12. Model for age-related hyperglycemia Chang AM, Halter JB. Aging and insulin secretion. Am J Physiol Endocrinol Metab 2003;284:E7–E12.

13. Neurohumoral Change Associated with aging

14. Clinical Tools Assessment for Diabetes in Elderly Le Roith D et al. J Clin Endocrinol Metab 104: 1520–1574, 2019

15. Principal approach Managing DM in Elderly

16. Management Diabetes In Elderly Sesti . G et al. Nutrition, Metabolism & Cardiovascular Diseases (2018) 28, 206e218

17. Target Therapy in Older Patient Diabetes Care 2020;43(Suppl. 1):S152–S162

18. Medical Used Elderly Diabetes Patients Le Roith D et al. J Clin Endocrinol Metab 104: 1520–1574, 2019

19. Medical Used in Elderly Diabetes Patients 1. Le Roith D et al. J Clin Endocrinol Metab 104: 1520–1574, 2019 1

20. Medical Used in Elderly Diabetes Patients Le Roith D et al. J Clin Endocrinol Metab 104: 1520–1574, 2019 Sesti . G et al. Nutrition, Metabolism & Cardiovascular Diseases (2018) 28, 206e218 1 2

21. Mechanism of Action DPP4i : Pleiotropic Effect DPP 4 –Inhibitor Ahrén , B., Foley, J.E. Improved glucose regulation in type 2 diabetic patients with DPP-4 inhibitors: focus on alpha and beta cell function and lipid metabolism.  Diabetologia   59,  907–917 (2016)

22. Comparasion Between DPP4 –inhibitor in Several Clinical Settings https://journalce.powerpak.com/ce/a-clinical-overview-of-dpp

23. DPP4 –Inhibitor in CV Protection Christopher El Mouhayyar et al. International Journal of Endocrinology. Volume 2020,

24. Effect DPP4 inhibitor Improve Microvascular Complication in DM Avogaro A and Padini G.A. Diabetes Care 2014 Oct; 37(10): 2884-2894.

25. Effect DPP4-I on Diabetic Nephropathy A.A Hasan and B. Hocher . Journal of Molecular Endocrinology (2017) 59, R1–R10

26. Antihyperglycemic Agents and Renal Function eGFR (mL/min/1.73 m 2 ): <15 15–29 30– 44 ≥ 6 CKD Stage 5 4 3 b 1 or 2 Acarbose Dapagliflozin Empagliflozin Pioglitazone U se alternative agent Dose adjustment not required D ose adjustment required Canagliflozin * 25 100 mg daily Caution Metformin Linagliptin Sitagliptin 50 50 mg daily 25 mg daily Saxagliptin 50 2.5 mg daily Aloglipti n Exenatide Liraglutide Repaglinide Gliclazide Glyburide Alpha- glucosidase Inhibitors Glimepiride Biguanides DPP-4 Inhibitors SGLT2 Inhibitors Insulin Secretagogues GLP-1 Receptor Agonists Insulins Rosiglitazone Thiazolidinediones 500 -1000 mg daily Dulaglutide 50 Exenatide QW 5 Li xisenatide Fluid retention 45-59 3 a 3 45 1 5 15 3 3 3 1 5 Do not initiate 30 30 6 6 6 6 6 6 30 6 45 30 1 5 * May be used for cardiorenal benefits in those with clinical CVD, A1C above target and eGFR >30 mL/min/1.73m 2 6 30 12.5 mg daily 6.25 mg daily 6 30 2018 Diabetes Canada CPG – Chapter 29. Chronic Kidney Disease in Diabetes 30 45 45

27. DPP 4 Inhibitor and Renal Impairment https://journalce.powerpak.com/ce/a-clinical-overview-of-dpp

28. Curr Diab Rep. 2018 Jun 21; 18(8): 53 . DM and HypoGlycemia

29. DPP4 Inhibitor and Hypoglycemia 31 AHA = antihyperglycemic agent; CI = confidence interval; DPP-4 = dipeptidyl peptidase 4; OR = odds ratio Adapted from: Tschöpe D et al. Cardiovasc Diabetol 2011; 10:66. Metformin Sulfonylureas Glucosidase inhibitors Glinides Thiazolidinediones DPP-4 inhibitors AHA monotherapy AHA dual combination therapy Sulfonylureas Glucosidase inhibitors Glinides Thiazolidinediones DPP-4 inhibitors 0.64 (0.50–0.82) 2.16 (1.75–2.67) 0.41 (0.17–1.02) 1.29 (0.82–2.02) 0.87 (0.56–1.36) 0.60 (0.34–1.07) 0.72 (0.58–0.89) 1.39 (1.13–1.72) 2.08 (1.44–2.99) 0.22 (0.03–1.60) 0.87 (0.46–1.63) 0.50 (0.28–0.89) 0.34 (0.16 – 0.72) 1.0 10.0 0.1 0.01 OR (95% CI) Add-on to metformin Less frequent More frequent Monotherapy

30. Propose Mechanism DPP-4 Inhibitor as Treatment in DM and Covid 19

31. Pasquel , F.J. and Umpierrez , G.E., 2020. Journal of Diabetes Science and Technology , p.1932296820923045.

32. Incretin Based Therapy In Sarcopenia issue Altuntaş Y. Approach Toward Diabetes Treatment in the Elderly. Med Bull Sisli Etfal Hosp 2019;53(2):96–102

33. SITAGLIPTIN EFFICACY FOR ELDERLY PATIENTS

34. ∆ -0.62±1.32% ∆ -0.60±0.92% ∆ -0.52±1.31% Sitagliptin therapy demonstrated comparable efficacy in elderly T2DM patients, versus non-elderly patients 20 No significant difference was observed in the change of HbA1c among the three groups Sitagliptin’s efficacy is “Age Independent” Use of age in decision making

35. Endurance of sitagliptin in elderly patients All the 3 doses (25 mg, 50 mg and 100 mg) of Sitagliptin are effective among elderly T2DM patients within all eGFR categories 21 Change in HbA1c levels as a function of sitagliptin dose Glycemic control improved significantly Effects sustained over as long as 4 years Progression of microvascular complications stabilized Sitagliptin has a durable effect and stabilizes microvascular complication progression in elderly patients

36. TECOS Study : Primary and key secondary c.v outcomes in older vs. younger Bethel et al, Diabetes Care 2017;40:494–501

37. TECOS Study : Primary and key secondary c.v outcomes in older (> 75 y.o ). Sitagliptin had neutral effects on cardiovascular risk and raised no significant safety concerns. Bethel et al, Diabetes Care 2017;40:494–501

38. Sitagliptin and Hypoglycemia in Elderly Type 2 DM Conclusion : Sitagliptin has the potential to both improve glycemic control and prevent hypoglycemia , and can be considered a potent alternative drug. Ujihara , N et al. Diabetol Int (2018) 9:56–65

39. STABLE EFFICACY OF SITAGLIPTIN ACROSS ALL STAGES OF RENAL IMPAIRMENT IN ACTIVE CONTROLLED STUDIES p= NS for all comparisons References: 1. Nauck M, et al. Diab Obes Metab 2007;9:194-205. 2. Ferreira J, et al. Diabetes Care. 2013;36:1067– 1073. 3. Ferreira JC, et al. Am J Kidney Dis. 2013;61:579–587

40. There are many factors that have to be considered in older diabetes Medication management of T2DM in Elderly requires consideration of specific factors such as multimorbidity, cognitive decline, frailty, complex medication regimens, polypharmacy and renal function. Focus on drug safety, improve Quality of live, and multidiscipline team approach Summary Target Glycaemic Control of A1C depend on specific condition