Polypharmacy in the Aging Patient: A Review of Glycemic Control in Older Adults With Type 2 Diabetes
Open accessAbstract
IMPORTANCE: There is substantial uncertainty about optimal glycemic control in older adults with type 2 diabetes mellitus. OBSERVATIONS: Four large randomized clinical trials (RCTs), ranging in size from 1791 to 11,440 patients, provide the majority of the evidence used to guide diabetes therapy. Most RCTs of intensive vs standard glycemic control excluded adults older than 80 years, used surrogate end points to evaluate microvascular outcomes and provided limited data on which subgroups are most likely to benefit or be harmed by specific therapies. Available data from randomized clinical trials suggest that intensive glycemic control does not reduce major macrovascular events in older adults for at least 10 years. Furthermore, intensive glycemic control does not lead to improved patient-centered microvascular outcomes for at least 8 years. Data from randomized clinical trials consistently suggest that intensive glycemic control immediately increases the risk of severe hypoglycemia 1.5- to 3-fold. Based on these data and observational studies, for the majority of adults older than 65 years, the harms associated with a hemoglobin A1c (HbA1c) target lower than 7.5% or higher than 9% are likely to outweigh the benefits. However, the optimal target depends on patient factors, medications used to reach the target, life expectancy, and patient preferences about treatment. If only medications with low treatment burden and hypoglycemia risk (such as metformin) are required, a lower HbA1c target may be appropriate. If patients strongly prefer to avoid injections or frequent fingerstick monitoring, a higher HbA1c target that obviates the need for insulin may be appropriate. CONCLUSIONS AND RELEVANCE: High-quality evidence about glycemic treatment in older adults is lacking. Optimal decisions need to be made collaboratively with patients, incorporating the likelihood of benefits and harms and patient preferences about treatment and treatment burden. For the majority of older adults, an HbA1c target between 7.5% and 9% will maximize benefits and minimize harms.
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Intense efforts to achieve HbA1c <7% among patients with long-standing type 2 diabetes increase risks associated with polypharmacy, contribute to treatment burden, and may increase the risk of hypoglycemia.
“The relatively intense efforts to achieve an HbA1c <7% among patients with long-standing T2DM increase the risks associated with polypharmacy, contribute to treatment burden (including financial burden), and may increase the risk of hypoglycemia.”
From Clinical management of stable coronary artery disease in patients with type 2 diabetes mellitus: a scientific statement from the American Heart Association (2020) · cites this paper as [192]
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- Authors
- Lipska, K. J., Krumholz, H., Soones, T., & Lee, S. J.
- Affiliations
- Yale University (US)
- Yale New Haven Hospital (US)
- Icahn School of Medicine at Mount Sinai (US)
- San Francisco VA Medical Center (US)
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2016-03-08
- Volume
- 315
- Issue
- 10
- Pages
- 1034
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- PMC
- PMC4823136
- OpenAlex
- W2295084748
- Cited by
- 309
- References
- 167
- Citations by year
- 2026: 15 · 2025: 15 · 2024: 11 · 2023: 15 · 2022: 22 · 2021: 42 · 2020: 31 · 2019: 39 · 2018: 37 · 2017: 42 · 2016: 34 · 2015: 5
- FWCI
- 50.88
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- JAMA (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute on Aging (K23AG048359, K23AG040779, P30AG021342, P30AG044281)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
- Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Keywords
- polypharmacy, older adults, type 2 diabetes, glycemic control, tight glycemic control, HbA1c targets, hypoglycemia risk, metformin, patient preferences, shared decision-making, treatment burden, microvascular outcomes, macrovascular events
- MeSH terms
- Aged, Aged, 80 and over, Diabetes Mellitus, Type 2, Female, Glycated Hemoglobin, Humans, Hyperglycemia, Hypoglycemia, Hypoglycemic Agents, Life Expectancy, Male, Time Factors, Blood Glucose Self-Monitoring, Randomized Controlled Trials as Topic, Polypharmacy, Patient Preference, Observational Studies as Topic
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