There is no evidence that using medications to achieve intense glycemic control in older adults with type 2 diabetes is beneficial (A1c under 7.0%). Among non-older adults, except for long-term reductions in myocardial infarction and mortality with metformin, using medications to achieve glycated haemoglobin levels less than 6 % is associated with harms, including higher mortality rates. Intense control has been consistently shown to produce higher rates of hypoglycemia in older adults. Given the long timeframe (approximately 8 years) to achieve theorized benefits of intense control, glycemic targets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0 – 7.5% in healthy older adults with long life expectancy, 7.5 – 8.0% in those with moderate comorbidity and a life expectancy < 10 years, and 8.0 – 8.5% in those with multiple morbidities and shorter life expectancy.

Conditions: Diabetes, Hyperglycemia, Hypoglycemia

Treatments: Hypoglycemia Medications, Metformin, Glyburide, Alpha-Glucosidase Inhibitor, Acarbose, Incretin Agent, DPP-4 Inhibitors, GLP-1 receptor Agonists, Insulin, Insulin Secretagogue, Meglitinide, Sulfonylurea, Thiazolidinediones (TZD), Pioglitazone

Sources

• 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 Sep 12;352(9131):854-65. (PubMed)
• ACCORD Study Group, Gerstein HC, Miller ME, Genuth S, Ismail-Beigi F, Buse JB, et al. Long-term effects of intensive glucose lowering on cardiovascular outcomes. N Engl J Med. 2011 Mar 3;364(9):818-28. (PubMed)
• Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller ME, Byington RP, Goff DC,Jr, Bigger JT, et al. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008 Jun 12;358(24):2545-59. (PubMed)
• ADVANCE Collaborative Group, Patel A, MacMahon S, Chalmers J, Neal B, Billot L, et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008 Jun 12;358(24):2560-72. (PubMed)
• Canadian Diabetes Association. 2013 Clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes. 2013 April 1;37:S1-212. (PDF)
• Duckworth W, Abraira C, Moritz T, Reda D, Emanuele N, Reaven PD, et al. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med. 2009 Jan 8;360(2):129-39. (PubMed)
• Finucane TE. "Tight control" in geriatrics: The emperor wears a thong. J Am Geriatr Soc. 2012 Aug;60(8):1571-5. (PubMed)
• Kirkman MS, Briscoe VJ, Clark N, Florez H, Haas LB, Halter JB, et al. Diabetes in older adults: A consensus report. J Am Geriatr Soc. 2012 Dec;60(12):2342-56. (PubMed)
• Montori VM, Fernandez-Balsells M. Glycemic control in type 2 diabetes: Time for an evidence-based about-face? Ann Intern Med. 2009 Jun 2;150(11):803-8. (PubMed)