Individualized Glycemic Goals for Older Adults Are a Moving
Several principles to guide a modern approach to HbA1c-lowering therapy:
-So long as it can be achieved safely, a therapeutic target HbA1c <7.0% will provide the best protection from complications of diabetes.
-Patients with life expectancy of less than 3–5 years are unlikely to benefit from tight glycemic control, although prognosis may be difficult to determine. Deintensification of drugs with high risk of hypoglycemia (i.e., insulins and insulin secretagogues) should be strongly considered in patients with limited life expectancy.
-Some coexisting medical conditions (e.g., major adverse cardiovascular disease, congestive heart failure, or diabetic kidney disease) represent indications for using an SGLT2 inhibitor or a GLP-1 receptor agonist, regardless of HbA1c, if the condition can be addressed by these medications, which can provide meaningful clinical benefit within time periods as short as 3–5 years.
-Insulin secretagogues (e.g., sulfonylureas) are associated with increased risk of life-threatening hypoglycemia and should be avoided whenever possible. This will become easier to accomplish as generic versions of new diabetes drugs become available (e.g., SGLT2 inhibitors and DPP-4 inhibitors).
-Insulins should be reserved for patients with late-stage T2D with insulin-dependent physiology due to advanced -cell failure. When insulin is prescribed, it may be appropriate to relax HbA1c targets (e.g., HbA1c <8.0% rather than <7.0%).