When oral agents fail: optimizing insulin therapy in the older adult.

OBJECTIVES: To evaluate strategies for managing older adults with type 2 diabetes who are inadequately controlled on oral agents and to consider when and how to transition older adults from usual care with oral agents to insulin therapy or incretin-based therapy.

DATA SOURCES: Live symposium presentation based on clinical practice and research, medical literature, and studies published between November 1999 and November 2008 on managing diabetes in older adults, government statistics, and medical society guidelines.

STUDY SELECTION: A study selection was performed using the following search terms: Basal Insulin, Diabetes, Elderly, Incretins, Insulin, Insulin Pharmacokinetics, Long-Term Care, Long-Term Complications, Medications, Oral antidiabetic, Senior, Treatment Goals. Articles were identified from various data sources containing information relevant to the early initiation of insulin and incretin-based drugs in the elderly as well as goals and treatment options in this group.

DATA EXTRACTION: Data were extracted by the author and Nicole Cooper (DesignWrite, LLC).

DATA SYNTHESIS: Recent guidelines suggest the need for early initiation of insulin in patients who fail to achieve or maintain goals on one or more oral agents. Basal-insulin therapy is convenient and appropriate for many older individuals who fail one or more oral agents. Prandial insulin coverage with basal-bolus insulin therapy or premixed insulin therapy may be useful in patients with significant postprandial hyperglycemia. Patients who need postprandial control also may benefit from using a glucagon-like peptide-1 (GLP-1) analog or a dipeptidyl peptidase-4 (DPP-4) inhibitor because they are unlikely to cause hypoglycemia, but reductions in hyperglycemia with these agents are limited.

CONCLUSION: Basal insulin therapy, basal-bolus insulin therapy, and premixed insulin therapy are useful options for older patients inadequately controlled on one or more oral agents. Older patients who require additional postprandial control may benefit from GLP-1 analogs or DPP-4 inhibitors. Additional research is needed to determine optimal therapy in older adults treated with oral agents who require more intensive therapy.