Management of type 2 diabetes mellitus in the elderly: role of the pharmacist in a multidisciplinary health care team

Figures & data

Table 1 Summary points for drugs used to treat diabetes in the elderly

Drug class/name	Possible drug or disease interactions	Adverse events that may limit use	Important notes
Alpha-glucosidase inhibitors^Citation9	Erratic oral intake; must take with main meals to be effective	Gastrointestinal effects	Adjust dose with renal or liver dysfunction
Meglitinides^Citation1 Incretin therapies DPP-4 inhibitors^Citation15	Frequent daily dosing Concomitant use with insulin secretagogues increases risk of hypoglycemia	Hypoglycemia, weight gain Headache, infection, dermatologic effects^Citation16	Rapid onset Effects are glucose dependent, so low risk for hypoglycemia Weight neutral Target PPG levels
Incretin therapies GLP-1 agonists^Citation15	Concomitant use with insulin secretagogues increases risk of hypoglycemia	Gastrointestinal effects (less than alpha-glucosidase inhibitors),^Citation15 pancreatitis, immune reactions (incidence less with liraglutide than exenatide)^Citation16	Effects are glucose dependent, so low risk for hypoglycemia Weight loss Target PPG levels Decrease blood pressure; improve other CVD markers^Citation16
Insulins^Citation17,Citation18	Erratic oral intake can increase risk of hypoglycemia; low vision and dexterity may limit use of vial and syringes, clinician inertia	Hypoglycemia	Better glycemic control if difficulty adhering to oral medications, receiving multiple oral medications, or not achieving glycemic targets than with oral medications alone Early use may restore and improve beta-cell function Insulin pens increase adherence for patients with low vision and/or dexterity issues
Metformin^Citation1	Impaired renal function	Lactic acidosis (rare but serious), gastrointestinal effects	Measure serum creatinine and liver function periodically and with any increase in dose Weight neutral versus placebo^Citation19 Avoid initiating in patients ≥80 years of age unless creatinine clearance is within normal limits
Pioglitazone^Citation14	Class III and class IV congestive heart failure	Weight gain, fluid retention, peripheral edema, fractures among women^Citation19	Hypoglycemia rare
Sulfonylureas^Citation4	Erratic oral intake can increase risk of hypoglycemia with long-acting agents	Hypoglycemia, weight gain	Avoid long-acting sulfonylureas; short-acting (ie, glipizide) minimize risk of nocturnal hypoglycemia, and may also help avoid hypoglycemia in patients with erratic oral intake

Abbreviations: CVD, cardiovascular disease; DPP-4, dipeptidyl peptidase IV; GLP-1, glucagon-like peptide 1; NPH, neutral protamine Hagedorn; PPG, postprandial glucose.

Table 2 Pharmacist-provided patient care and associated outcomes in older patients with type 2 diabetes mellitus

Study	Methods	Results
Cranor et al^Citation24	Quasi-experimental, longitudinal, pre and post cohort trial design 12 community-based pharmacists trained in diabetes education Asheville Project Change in clinical and economic outcomes before and after up to 5 years of implementation of services	n = 620 financial cohort, n = 565 clinical cohort Baseline median age 48 years Median A1c decreased by 0.8% after first follow-up visit (P < 0.001) LDL-C decreased by 2.5 mg/dL after the first follow-up visit (P = 0.13) Total direct medical costs decreased by US$1662–$3356 per patient per year depending on the follow-up year, despite increases in mean prescription costs
Fera et al^Citation5	Prospective, observational, pre- and post-cohort trial design Collaborative practice model Community-based pharmacists Evidence-based guidelines Clinical and economic outcomes Diabetes Ten City Challenge Change in clinical and economic outcomes before and after 1 year of implementation of services	N = 573 42% were 60 years or older Mean A1c decreased by 0.4% (P = 0.002) Mean LDL-C decreased by 4 mg/dL (P < 0.001) Mean SBP decreased by 3 mmHg (P < 0.001) Average total health care costs per patient per year decreased by US$1079 (7.2%) Influenza vaccination rate increased by 33% Foot examination rate increased by 40%
Jameson and Baty^Citation25	Prospective, randomized, controlled trial Pharmacist management versus usual medical care Change in A1c after 1 year of care Poorly controlled diabetes (A1c > 9%) One pharmacist with advanced diabetes education training Intervention consisted of targeted patient outreach program plus medication management, patient education, disease control by a pharmacist Control group used targeted patient outreach programs and registries	N = 103 (intervention group n = 52, control group n = 51) Mean age 49 years Mean A1c decreased by 1.5% for the intervention group and 0.4% for the control group (P = 0.06) A1c decreased by at least 1% for 67.3% versus 41.2%, respectively (P = 0.02) Male and nonwhite patients had greater improvement in A1c than female or white patients

Abbreviations: A1c, glycosylated hemoglobin; LDL-C, low-density lipoprotein cholesterol; SBP, systolic blood pressure.

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