New guideline offers recommendations for older patients with diabetes or prediabetes

The Endocrine Society's new clinical practice guideline recommends lifestyle therapy, then metformin, then second-line drugs (but not sulfonylureas and glinides) or insulin for diabetes patients ages 65 years and older, among other advice.


The Endocrine Society recently issued a clinical practice guideline on diabetes treatment in patients age 65 years and older.

The guideline takes into consideration the overall health and quality of life of older adults, the society noted. It was published online March 23 by the Journal of Clinical Endocrinology and Metabolism.

The guideline recommends:

  • A lifestyle program, not metformin, for patients with prediabetes.
  • Diabetes regimens designed specifically to minimize hypoglycemia, with lifestyle modification (but not restrictive diets) as the first-line treatment, then metformin, then the addition of other oral or injectable agents and/or insulin. (The guideline also recommends avoiding sulfonylureas and glinides, using insulin sparingly, and keeping regimens as simple as possible.)
  • Periodic cognitive screening of older patients with diabetes.
  • A target blood pressure of 140/90 mm Hg for patients ages 65 to 85 years, with an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker as first-line therapy.
  • An annual lipid profile. (The guideline refrained from endorsing specific LDL cholesterol targets but did recommend fish oil and/or fenofibrate to reduce the risk of pancreatitis in patients with fasting triglyceride levels >500 mg/dL.)
  • Caution about the use of glinides, rosiglitazone, pioglitazone, and dipeptidyl peptidase-4 inhibitors in patients with heart failure.
  • Low-dose aspirin for secondary prevention of cardiovascular disease after careful assessment of bleeding risk and collaborative decision-making.

The guideline also offered guidance on treatment of older patients in hospitals or long-term care facilities, recommending blood glucose targets of 100 to 140 mg/dL (5.55 to 7.77 mmol/L) fasting and 140 to 180 mg/dL (7.77 to 10 mmol/L) postprandial while avoiding hypoglycemia. Routine measurement of HbA1c during admission to the hospital was also recommended. The guideline offered additional recommendations related to eye complications, neuropathy, falls, lower-extremity problems, chronic kidney disease, and the role of the endocrinologist and diabetes care specialist.

The American Diabetes Association also recently updated its Standards of Medical Care in Diabetes, a “living” document in which updates are incorporated on an ongoing basis due to new medication approvals or publications.

The changes made on March 27 include:

  • a new recommendation that icosapent ethyl be considered for patients who have diabetes and cardiovascular disease or other cardiac risk factors and controlled LDL cholesterol levels but elevated triglyceride levels while taking a statin.
  • a reduction in the minimum estimated glomerular filtration rate at which dapagliflozin may be prescribed from 60 mL/min/1.73 m2 or higher to 45 mL/min/1.73 m2 or higher.
  • other revisions based on a trial that found dapagliflozin to be associated with reductions in heart failure hospitalizations and progression of chronic kidney disease.

A summary of the changes and the complete standards were published by Diabetes Care.