title: Noninsulin treatment of type 2 diabetes mellitus in geriatric patients: a review.
abstract: BACKGROUND
  Currently, 42% of the US population with diabetes is aged ≥65 years.
  
  
  OBJECTIVE
  The aim of this review was to discuss the efficacy and tolerability of noninsulin therapies for type 2 diabetes mellitus (T2DM), with an emphasis on patients aged ≥65 years.
  
  
  METHODS
  PubMed and EMBASE (1977-2010) were searched using the terms geriatric, elderly patients, type 2 diabetes mellitus, metformin, secretagogues, thiazolidinediones (TZDs), alpha-glucosidase inhibitors, dipeptidyl peptidase-4 (DPP-4) inhibitors, and glucagon-like peptide-1 (GLP-1) receptor agonists. Articles were included if they were clinical trials, reviews, or meta-analyses.
  
  
  RESULTS
  More than 10 classes of noninsulin treatments are available for T2DM. However, most treatments have been evaluated only in trials in patients aged <65 years, and trials in older populations are scarce. Therefore, health care providers should consider the overall benefit to risk, with a focus on risk factors in older patients. A1C reductions range from 0.6% to 2%, with similar decreases observed for metformin, TZDs, sulfonylureas (SUs), glinides, and GLP-1 receptor agonists Treatment-associated adverse events vary. The prevalence of hypoglycemia is high with the secretagogues, SUs, and glinides (20% with glibenclamide or glipizide, 16% with repaglinide). The TZDs have been associated with an increased risk for heart failure (adjusted ratio = 1.60; 95% CI, 1.21-2.10; P < 0.001) compared with the other oral therapies. Gastrointestinal adverse events have been commonly reported with metformin (38% of patients), which is contraindicated in cases of renal insufficiency. Use of the GLP-1 RAs liraglutide and exenatide have been associated with comparable weight reductions of ∼3 kg and with a low risk for hypoglycemia (prevalence, 4% with exenatide 10 μg; ∼5% with liraglutide 1.2 or 1.8 mg). Treatment with the GLP-1 RAs has been associated with transient gastrointestinal reactions, mainly nausea.
  
  
  CONCLUSIONS
  The selection of noninsulin treatments in older patients with T2DM should be individualized based on patient assessment and on careful evaluation of the potential benefits (glycemic and extraglycemic) and risks (ie, hypoglycemia, weight gain, cardiovascular risks). More clinical trials in older patients, especially those aged ≥65 years, with T2DM are needed.
authors.affiliation: Orland Primary Care Specialists, LLC, Orland Park, Illinois 60467, USA. orlandprimarycaremed@hotmail.com
authors.forename: F Wilford
authors.initials: FW
authors.lastname: Germino
mesh_terms: D000367:Age Factors; D000368:Aged; D000375:Aging; D015415:Biomarkers / Q000097:blood; D001786:Blood Glucose / Q000187:drug effects / Q000378:metabolism; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000188:drug therapy*; D019317:Evidence-Based Medicine; D006442:Glycated Hemoglobin / Q000378:metabolism; D006801:Humans; D007004:Hypoglycemic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D018579:Patient Selection; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D001786:Blood Glucose; D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; C517652:hemoglobin A1c protein, human