Diabetes medication management recommendations for older adults: A systematic review of the Western Pacific region

Abstract

Aim

The Western Pacific region has the fastest aging population and 38% of the world's diabetes population. It is unknown to what extent medication management recommendations are included for older adults in type 2 diabetes (T2D) clinical practice guidelines (CPGs).

Method

MEDLINE, Embase, Scopus, guideline‐specific registries and gray literature searches were performed in November 2024. Data were extracted on guideline characteristics and recommendations relevant to older adults, dementia, frailty, co‐morbidities associated with aging or end‐of‐life. Quality appraisal was performed using the AGREE II (Appraisal of Guidelines, Research and Evaluation) tool.

Results

From the 37 countries and areas of the Western Pacific region, 16 CPGs were identified, of which 15 included 1–29 relevant recommendations. Thirteen CPGs recommended less stringent and/or individualized glycemic targets focused on reducing hypoglycemia for older adults. Five CPGs recommended individualized antihyperglycemic treatment choices. Seven CPGs included recommendations about de‐intensification/simplification of complex regimens. The quality of CPGs varied, with scope and purpose rated the highest.

Conclusions

There was heterogeneity in the number of recommendations within CPGs; however, none comprehensively addressed the T2D medication management needs of older adults or those living with dementia, frailty or receiving end‐of‐life care. Collaboration between diabetes and geriatric societies as well as the assistance of higher‐income countries in helping those with less resource availability could provide a way forward to improving future CPGs. Geriatr Gerontol Int 2025; 25: 717–729.

Background

World Health Organization (WHO) Western Pacific region priorities for 2020–25 include addressing non‐communicable diseases and aging. The region is home to more than 84 million adults aged 75 years and older, and this number is expected to triple by 2050. ¹ An estimated 38% of all adults with diabetes live in the Western Pacific. ² Older adults with type 2 diabetes (T2D) have a high prevalence of multimorbidity and frailty. ³ There is increasing need for guidance in relation to best practice management of diabetes in the context of age‐related conditions including dementia, frailty, and end‐of‐life care. ⁴

There are a range of considerations when managing diabetes in those living with dementia and frailty and at end‐of‐life. Antihyperglycemic agents reduce the risk of micro‐ and macro‐vascular complications ⁵ but are associated with hypoglycemia. ⁶ Hypoglycemia is associated with cognitive impairment, falls, fractures, and seizures in older adults. ³ Diabetes goals of care in older adults at end‐of‐life include preserving quality of life, minimizing adverse drug events (ADEs), and avoiding metabolic decompensation. ⁷ Older adults with T2D often have polypharmacy, which may contribute to drug–drug interactions, ADEs, and medication errors. ⁵ Therefore, older adults may require different treatment approaches than the general population.

Clinical practice guidelines (CPGs) promote best practice by providing evidence‐based recommendations on appropriate treatment and care. Systematic reviews have evaluated CPG recommendations for oral T2D medications in Europe and North America. ⁸ , ⁹ , ¹⁰ These CPGs contained few recommendations for age‐related conditions (e.g., dementia, frailty). One systematic review of global T2D CPGs reported recommendations that favored individualized care, but few provided pharmacotherapeutic recommendations for frailty. However, this review did not consider end‐of‐life or palliative care and only included three Western Pacific CPGs. ¹⁰ The Western Pacific region is diverse in geography, populations, economics, health infrastructure, and health literacy. Thus, findings from these three CPGs are unlikely to be generalizable to other Western Pacific countries,¹¹ and it is largely unknown to what extent recommendations for older adults and those living with dementia or frailty and receiving end‐of‐life care are made in Western Pacific T2D CPGs.

The objective was to identify Western Pacific region T2D CPGs and investigate whether antihyperglycemic medication management recommendations consider older adults and those living with dementia or frailty or receiving end‐of‐life care.

Methods

The protocol was registered on PROSPERO (ID: CRD42023418153). The Population, Intervention, Comparators, Attributes of the CPG and Recommendation Characteristics (PICAR) Statement was used to develop the review question. ¹² This manuscript was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines ¹³ (Supplementary Information).

Eligibility criteria

The review included CPGs for adults with T2D within the WHO Western Pacific region. CPGs were defined according to the Institute of Medicine as “statements that include recommendations, intended to optimize patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.” ¹⁴ We included national CPGs developed without a systematic review that referenced international CPGs developed on the basis of a systematic review. CPGs needed to be produced, endorsed, or adopted by a national professional organization or government body; published since 2013; and be the most recent version. CPGs were excluded for type 1 diabetes, gestational diabetes, and pediatrics/adolescents. Local or regional guidelines were also excluded, as were CPGs focused on management of co‐morbidities (e.g., hypertension medication in T2D).

Search strategy

Ovid MEDLINE, EMBASE and Scopus were searched on November 11th 2024 (Supplementary Information). Registries searched included the Guidelines International Network (GIN) registry, MAking Grade the Irresistible Choice (MAGIC) app, and TRIP UK database. Gray literature searches were performed by conducting citation searching, pragmatic internet searches (Google searches with each country/territory AND diabetes AND “society OR organisation” AND guideline), and contacting relevant diabetes organizations from each country by email.

Data screening

Initial database searches were performed independently by DG and transferred onto a referencing software package for duplicate removal (Endnote 20). Search results were exported into Covidence for title and abstract screening and full text review by two researchers (DG, YE). Additional results from registry searches, gray literature searches, and pragmatic searching of Western Pacific region diabetes organizations were identified by one researcher (DG) and checked by a second (MA). All CPGs with antihyperglycemic medication management recommendations for T2D were identified, and then whether these CPGs included recommendations for older adults, those living with dementia or frailty or receiving end‐of‐life care was determined. If disagreements arose, a third reviewer was consulted to reach consensus.

Data extraction and analysis

Data extraction tables were developed and piloted. Data were extracted in duplicate by two reviewers (DG, YE). If any inconsistencies between data extractors were present, senior authors (ER, JSB) were consulted. Data extraction from CPGs published in languages other than English was performed by reviewers with proficiency in the respective languages (SH, YH, KW).

Data extracted included CPG characteristics (Table 1) and medication management recommendations in older adults, those living with dementia, frailty, co‐morbidities associated with aging, or receiving end‐of‐life care (Table 2). Quantitative data were not pooled for meta‐analysis, as this was a review of CPGs. Recommendations were grouped by glycemic targets, first‐choice antihyperglycemic agent, antihyperglycemic agents to avoid, monitoring considerations, and deprescribing.

Table 1.

Guideline characteristics

Country, Guideline title	Developing Organization(s)	Year	Target population	Summary of methods	Type of recommendations (certainty of evidence grading levels)	Number of relevant recommendations for each population type
Australia, General practice management of type 2 diabetes 16	Royal Australian College of General Practitioners, Diabetes Australia	2020	T2D	Adopted recommendations from organizations including the National Health and Medical Research Council, the Scottish Intercollegiate Guidelines Network, Diabetes Canada, the American Diabetes Association, and other relevant sources.	EBR and PP (Grades A‐E)	4 – OA 3 – EoL 1– Co‐morbidities
Australia, Living Evidence for Diabetes Consortium Australian Evidence‐Based Clinical Guidelines for Diabetes 17	Australian Diabetes Society	2024	Diabetes	GRADE method, which includes five steps: (1) assign priori ranking of studies based on whether they are randomized control trials or observational studies; (2) “downgrade” or “upgrade” initial ranking; (3) assign grade for the quality of evidence; (4) consider factors that impact the strength of the recommendation; (5) make a “strong” or “weak” recommendation.	EBR and PP (Recommendation for/against, conditional recommendation for/against)	4 – Co‐morbidities
Cambodia, Clinical practice guidelines type 2 diabetes: a continuum of care for diabetes patients both with and without complications at Non‐Communicable Disease (NCD) clinics/Rest homes 18	Bureau for Prevention & Control Department of Preventive Medicine	2015	T2D	The guideline was adapted from the “Type 2 Diabetes. Practical Targets and Treatments,” published by the Asian‐ Pacific Type 2 Diabetes Policy Group.	Not reported	1 – OA
China, Standards of medical care for type 2 diabetes in China 19	Chinese Diabetes Society	2019	T2D	Experts in cardiovascular diseases, psychiatric diseases, nutrition, and traditional Chinese medicine worked with endocrinologists to review recent clinical research in diabetes.	EBR (levels A, B and C)	4 – OA 1 – Co‐morbidities
China, Guideline for the prevention and treatment of type 2 diabetes mellitus in China 20	Chinese Diabetes Society	2020	T2D	Updated version of the previous guideline (2013 version). Use of an expert panel using domestic and international epidemiological data, results of clinical trials, relevant guidelines, China's prevention, treatment and research data, expert opinions of nearly 100 experts.	Not reported	2 – OA 2 – Dementia 2 – Frailty 2 – EoL 1 – Co‐morbidities
China, Guideline for the Management of Diabetes Mellitus in the Elderly in China (2024 Edition) 21	National Center of Gerontology, Chinese Society of Geriatrics and Diabetes Professional Committee of Chinese Aging Well Association	2024	Diabetes mellitus	Searches were conducted on multiple databases, and evidence was rated as level A, B, or C. The Guideline Writing Group presented proposed recommendations, relevant evidence, and described the level of evidence to the Expert Panel members, who confirmed the literature and evidence. The full text was compiled in accordance with the fundamental specifications for the formulation of clinical guidelines.	EBR (Levels A, B, C)	18 – OA 3 – Dementia 3 – Frailty 1 – EoL 6 – Co‐morbidities
Cook Islands, Hypertension, Cardiovascular, Diabetes and Obesity Prevention and Management Guidelines 22	Ministry of Health	2013	Hypertension, cardiovascular, diabetes and obesity	Guidelines were developed by a multidisciplinary review group with assistance from the World Health Organisation.	Not reported	1 – OA
Japan, Japanese Clinical Practice Guideline for Diabetes 23 (Synopsis of the Japanese Diabetes Society/Japanese Geriatric Society clinical practice guidelines for the treatment of diabetes in the elderly 2017)	Japan Diabetes Society	2019	Diabetes	Statements and strength of recommendations were developed for clinical questions following a systematic review of evidence from several resources. The grade of the recommendation was determined by voting from the clinical guideline committee members with consideration of the certainty of the overall evidence, balance of benefits and harms, patient preferences/values, and costs.	EBR and expert opinion (Grades A and B, Levels 1–3)	5 – OA 4 – Dementia 1 – Frailty 1 – EoL
Japan, Diabetes Treatment Guidelines for the Older Adults 24	Japan Diabetes Society, Japan Geriatric Society	2023	Diabetes	(Same as above)	EBR and expert opinion (Grades A and B, Levels 1–3)	5 – OA 3 – Dementia 2 – Frailty 3 – Co‐morbidities
Korea, Clinical Practice Guidelines for Diabetes Mellitus in Korea 25	Korean Diabetes Association	2023	Diabetes mellitus	The Korean Diabetes Association evidence level was classified into four categories: randomized controlled trials (RCTs), including systematic reviews, meta‐analyses, and RCTs; non‐randomized controlled studies; others; and expert opinions.	EBR and expert opinion (RCT or NRS, general or limited)	6 – OA 5 – Co‐morbidities
Malaysia, Management of Type 2 Diabetes Mellitus (6th edition) 26	Ministry of Health	2020	T2D	The grading of recommendations followed the American Heart Association system. Guidelines were reviewed by an external multidisciplinary group and presented to the Ministry of Health for review and approval.	EBR and PP (Grades A–C, Levels I–III)	6– OA 1 – Dementia 1 – EoL
Philippines, Philippine Practice Guidelines on the Diagnosis and Management of Diabetes Mellitus 49	Unite for Diabetes Philippines: A Coalition of Organizations Caring for Individuals with Diabetes Mellitus	2014	Diabetes mellitus	(1) Guideline adaptation using the ADAPTE process; and (2) de novo development of guideline statements whenever there were no guidelines (e.g., on issues regarding the use of alternative methods for diagnosis of diabetes and herbal medications or alternative medicines for the treatment of diabetes mellitus.)	EBR (Grades A–D)	None
Republic of Marshall Islands, Diabetes Management Guidelines 27	Ministry of Health	2016	Diabetes mellitus	Guideline development involved consultations with specialists, family practitioners, and others working in hospitals in the Marshall Islands. Marshall Islands context was taken into consideration while using evidence‐based guidelines from the American Diabetes Association and the American Association of Clinical Endocrinologists and other guidelines from within the region.	Not reported	2 – OA 2 – Co‐morbidities
New Zealand, Type 2 Diabetes Management Guidance 28	New Zealand Society for the Study of Diabetes	2023	T2D	Review of CPGs (American Diabetes Association, European, Australian, Canadian) with a multidisciplinary group. Recommendations were made through reaching consensus.	Not reported	3 – OA 2 – Dementia 1 – Frailty 1 – EoL 6 – Co‐morbidities
Samoa, Samoa Diabetes Management Guide 29	Ministry of Health	2024	Diabetes –Primarily type 2 diabetes	Adapted and adopted CPGs from New Zealand and UK. Adapted evidence‐based medicine to the local contexts based on information, recommendations and limitations from previous local guidelines and experiences within the Guidelines Group.	Not reported	2 – OA 2 – Dementia 1 – Frailty 1 – EoL 5 – Co‐morbidities
Singapore, Diabetes Mellitus 30	Ministry of Health	2014	Diabetes mellitus	Produced by a multidisciplinary committee including a patient representative, appointed by the Ministry of Health. The Guideline was developed by the adaptation of existing guidelines, a review of relevant literature and by expert clinical consensus with consideration of local practice.	EBR and PP (Grades A–D, Levels 1–4)	1 – OA 4 – Co‐morbidities

EBR, evidence‐based recommendation; GRADE, Grading of Recommendations, Assessment, Development, and Evaluations; OA, older adults; EoL, end‐of‐life; CPG, clinical practice guideline; PP, practice point; T2D, type 2 diabetes.

Table 2.

Summary of guideline recommendations

	Glycemic targets	Choice of antihyperglycemic	Antihyperglycemics to avoid	Monitoring considerations	Deprescribing ‡
Older adults †	13 CPGs: Australia 2018, Cambodia, China 2019, China 2020, China 2024, Cook Islands, Japan 2019, Japan 2023, Korea, Malaysia, Republic of Marshall Islands, Samoa, New Zealand Higher HbA1C targets (7–8.1%) 16 , 20 , 26 , 27 , 28 , 29 Stratified goals for glycemic control based on health status of older people 21 Individualized targets with the aim to reduce risk of hypoglycemia 16 , 18 , 19 , 21 , 22 , 23 , 24 , 25	9 CPGs: China 2019, China 2020, China 2024, Japan 2019, Japan 2023, Korea, Malaysia, Marshall Islands, Singapore Initiate therapy with low‐dose, short‐acting oral glucose‐lowering agents that lower the risk of hypoglycemia 19 , 21 , 23 , 24 , 30 Metformin as first line provided there are no contraindications 20 , 27 Principle choice is similar in the elderly to in younger patients, and consideration of drug–drug and adverse reactions should be made and of factors that may affect adherence to medications 21 , 25 , 26	6 CPGs: Australia 2018, China 2024, Japan 2019, Malaysia, Marshall Islands, Samoa Sulfonylureas, particularly glibenclamide, should be avoided in those >60 years of age 26 , 27 , 29 Drugs that increase risk of heart failure should be used with caution and are contraindicated in older patients at high risk of heart failure 21 Overtreatment should be avoided as well as multi‐drug combinations that could increase hypoglycemia risk 16 , 23	6 CPGs: Australia 2018, China 2019, China 2024, Korea, Malaysia, New Zealand Individualized treatment, health education, nursing and rehabilitation strategies should be developed according to health status 21 Actively assess for geriatric syndrome and renal function on a yearly basis 21 Evaluate co‐morbidities or complications of diabetes and comprehensive geriatric assessment 21 , 25 Continuous glucose measurements should be considered for multiple insulin regimens 25 Periodic comprehensive evaluations (e.g., comprehensive creation of individualized care plans including glucose control targets, drug treatment, and screening for diabetes‐related complications) 16 , 19 , 21 , 25 , 26 , 28	3 CPGs: Australia 2018, China 2024, Japan 2023 De‐intensification (or simplification) of complex regimens to reduce the risk of hypoglycemia 16 , 24 De‐intensification of insulin therapy should be emphasized 21
Older adults living with dementia	5 CPGs: China 2020, China 2024, Japan 2019, Japan 2023, Samoa It is unclear whether tight glycemic control is effective in preventing cognitive impairment or onset of dementia 24 A more relaxed target for those with cognitive disfunction 21 HbA1c <7.5–<8% 20 , 23 , 24 , 29		3 CPGs: Japan 2023, New Zealand, Samoa SGLT‐2 inhibitors – not highly recommended in those aged 65–74 years with dementia, sarcopenia, or ADL decline or in those aged 75 years or older 24 Sulfonylureas should be used with caution in those with cognitive impairment 28 , 29	2 CPGs: China 2024, Malaysia Diabetic patients with cognitive disorders are more likely to experience hypoglycemic events 21 Cognitive function should be assessed annually to determine adherence to prescribed management 21 , 26	1 CPG: Japan 2023 Insulins: consider reducing the number of administration times 24
Older adults living with frailty	4 CPGs: China 2020, Japan 2019, Japan 2023, Samoa Low HbA1c is a risk factor for falls/fractures or frailty 23 , 24 HbA1c <7.5–<8% 20 , 29	1 CPG: China 2024 Highly individualized glycemic therapies should consider frailty status 21	1 CPG: Japan 2023 Same as above	1 CPG: China 2024 Assess for sarcopenia and frailty 21
Co‐morbidities associated with aging	1 CPGs: China 2020 HbA1c <8%–<8.5% 20 Patients with a combination of ≥3 chronic diseases other than diabetes mellitus (including stroke, hypertension, stage 1–3 kidney disease, osteoarthritis, etc.) 20	7 CPGs: Australia 2018, Australia 2024, China 2024, Japan 2023, Korea, New Zealand, Samoa SGLT‐2is or GLP‐1ras may be considered in those with cardiovascular disease, multiple cardiovascular risk factors, and/or kidney disease 16 , 17 , 21 , 25 , 28 , 29 DDP‐4is may be considered in those with cardiovascular disease, multiple cardiovascular risk factors, and/or kidney disease who are unable to access or tolerate SGLT‐2is or GLP‐1ras 17	8 CPGs: Australia 2023, China 2019, China 2024, Japan 2023, Marshall Islands, New Zealand, Samoa, Singapore Metformin should not be used in individuals with severe renal or hepatic impairment 17 , 19 , 21 , 24 , 27 , 28 , 29 , 30 Thiazolidinediones are contraindicated in patients with acute coronary syndrome, ischemic heart disease, and all classes of heart failure and may increase risk of fracture; should be avoided in those with or at high risk of osteoporosis 24 , 27 , 28 , 30 Sulfonylureas should not be used in end‐stage renal or liver failure 28		3 CPGs: New Zealand, Samoa, Singapore Metformin doses should be reduced in renal impairment and ceased if eGFR is below 30 mL/min/1.73m2, 28 , 29 , 30 A >20% dose reduction of basal insulin is often required if frequent and/or severe hypoglycemia occurs 28
Receiving end‐of‐life care	4 CPGs: Australia 2018, China 2020, China 2024, Samoa HbAlc <7.5%–<8.5% 16 , 20 , 29 Less stringent glycemic targets that avoid both hypo‐ and hyperglycemia and promote quality of life 16 , 21	1 CPG: Japan 2019 “Treatment should be focused on decreasing symptoms of marked hyper‐ and hypo‐glycemia and alleviating pain while honoring their preferences” 23		1 CPG: China 2020 Monitoring should be individualized, focusing on symptom management 20	1 CPG: Malaysia “Treatment de‐escalation or discontinuation should be considered once organ failure develops or end of life care is initiated” 26

ADL, activities of daily living; CPG, clinical practice guideline; DDP4i, dipeptidyl peptidase‐4 inhibitor; GLP‐1ra, Glucagon‐Like Peptide‐1 receptor agonist; HbA1c, Glycated Hemoglobin; RACGP, Royal Australian College of General Practitioners; SGLT2i, Sodium Glucose Transporter 2 inhibitor; T2D, type 2 diabetes.

^† Owing to differences in life expectancies across the Western Pacific region, the definition of older adults was country‐specific (e.g., use of the term ‘older adults’ or age cut‐off such as >60 years old).

^‡ Deprescribing was operationally defined as the process to simplify, reduce, or completely withdraw medication where the likely harms outweigh the benefits in the individual, supervised by a healthcare professional. ⁵⁰

Quality appraisal

CPGs were appraised using the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument. AGREE II is an internationally validated instrument including six domains. CPGs were each appraised by two reviewers (DG, SF, SH, YH, KW) in their respective languages. The six domains were rated on a Likert scale (1 = “strongly disagree”; 7 = “strongly agree”), and ratings for each domain were calculated per the AGREE II user's manual. ¹⁵ Differences in ratings were reviewed if they were greater than 30%, and the mean scores for each domain were reported.

Results

Search and guideline characteristics

The search strategy identified 3410 results, with 16 CPGs identified, of which 15 included at least one medication management recommendation relevant to older adults, those living with dementia, frailty or end‐of‐life (Fig. 1).

Figure 1.

PRISMA flow diagram.

CPGs with at least one relevant medication management recommendation were from Australia (n = 2)16, 17 Cambodia (n = 1),¹⁸ China (n = 3)19, 20, 21 Cook Islands (n = 1),²² Japan (n = 2)23, 24 Korea (n = 1),²⁵ Malaysia (n = 1),²⁶ Marshall Islands (n = 1),²⁷ New Zealand (n = 1),²⁸ Samoa (n = 1),²⁹ and Singapore (n = 1) ³⁰ (Table 1).

Guideline recommendations

Fifteen CPGs contained between 1 and 29 medication management recommendations relevant to older adults, dementia, frailty, or end‐of‐life. None of the CPGs included recommendations for all population groups of interest for all medication management considerations (Table 2).

Glycemic targets

Thirteen of the included CPGs provided glycemic target recommendations for one or more of our populations of interest (older adults n = 13, frailty n = 5, dementia n = 6, end‐of‐life n = 5, co‐morbidities n = 1). Overall, the recommendations stated that individualized targets are required, and less stringent targets are often appropriate for older adults, specifically those living with dementia, frailty, or end‐of‐life. Targets varied between CPGs, with some recommending HbA1c targets of <7–8% for older adults and <8% for end‐of‐life. One CPG also recommended a blood glucose level range of 6–15 mmol/L for end‐of‐life. ¹⁶

First‐choice antihyperglycemics

Ten CPGs provided recommendations for antihyperglycemic choice (older adults n = 9, frailty = 1, co‐morbidities n = 7, end‐of‐life = 2). Metformin was recommended as the first‐line choice for older adults if not contraindicated in two CPGs. ²⁰ , ²⁷ Others recommended a low‐dose, short‐acting agent,³⁰ considering individual's nutritional status, social background, psychosomatic function, and the antihyperglycemics pharmacological profile ²³ , ²⁴ or avoiding hypoglycemia. ¹⁹ In those with co‐morbidities associated with aging, such as renal disease or cardiovascular disease (CVD), the use of a sodium–glucose cotransporter 2 inhibitor (SGLT2i) or glucagon‐like peptide 1 receptor agonists (GLP‐1ra) was recommended. ¹⁶ , ¹⁷ , ²¹ , ²⁵ , ²⁹ SGLT2is were also recommended in those with CVD or with multiple cardiovascular risk factors. ¹⁶ , ¹⁷ , ²⁵ , ²⁹ , ³¹ A dipeptidyl peptidase‐4 inhibitor (DPP4i) was suggested if an SGLTi or GLP1ra was not tolerated. ¹⁷ It was recommended that care during end‐of‐life focused on decreasing symptoms of both hyper‐ and hypoglycemia. ²³

Antihyperglycemics to avoid

Ten CPGs recommended avoiding specific antihyperglycemics (older adults n = 7, frailty n = 1, dementia = 3, co‐morbidities associated with aging n = 8). Antihyperglycemics to avoid in older adults were sulfonylureas, metformin in severe renal or hepatic impairment, and thiazolidinediones in CVD and in patients with high fracture risk. ¹⁷ , ¹⁹ , ²⁴ , ²⁷ , ²⁸ , ³⁰ Avoiding overtreatment and multi‐drug combinations that may increase hypoglycemic risk or falls was also recommended. ¹⁶ , ²³ SGLT‐2 inhibitors were not highly recommended in those aged 75 and over. ²⁴

Monitoring

Monitoring recommendations were present in seven CPGs (older adults n = 6, frailty n = 1, dementia n = 2, end‐of‐life = 1). For older adults, periodic comprehensive geriatric assessments including individualized care plans for glucose control targets, medication regimens, and monitoring plans were recommended in three CPGs. ¹⁶ , ¹⁹ , ²⁶ For those living with dementia, monitoring of cognitive function was recommended as well as assessing activities of daily living and quality of life annually. ²³ Renal function was recommended to be assessed annually as well as active monitoring for geriatric syndrome. ³¹ Older adults should also be assessed for sarcopenia and frailty. ²¹ One CPG recommended that end‐of‐life monitoring of glucose levels should be individualized and not necessarily “numbers based”. ²⁰

Deprescribing

Seven CPGs included a deprescribing recommendation (older adults n = 3, dementia n = 1, end‐of‐life n = 1, co‐morbidities n = 3). Deprescribing recommendations generally consisted of recommendations for deintensification (or simplification) of complex regimens to reduce the risk of hypoglycemia. ¹⁶ , ²⁴ Three CPGs provided recommendations to deprescribe specific antihyperglycemic medications. These included reducing doses of metformin in renal impairment or ceasing if eGFR was below 30 mL/min/1.73 m², ²⁸ , ³⁰ as well as reducing doses or administration times of insulin. ²³ , ²⁸

Quality assessment

Five CPGs ¹⁶ , ¹⁷ , ²¹ , ²³ , ²⁵ were rated as having the highest overall quality, with scores for all domains above 50%. All CPGs were rated over 50% in the domain of scope and purpose. Following this, stakeholder involvement was the next domain to receive the highest overall scores across all CPGs (45%–99%). The biggest differences in domain scores between CPGs were between rigor of development (24%–98%) and editorial independence (18%–100%) (Table 3).

Table 3.

AGREE II quality appraisal

Guideline	Domain 1: Scope and purpose	Domain 2: Stakeholder involvement	Domain 3: Rigor of development	Domain 4: Clarity of presentation	Domain 5: Applicability	Domain 6: Editorial independence	Mean overall score
Australia 2018	77%	76%	79%	95%	66%	100%	83%
Australia 2024	99%	99%	98%	95%	94%	100%	98%
Cambodia	83%	67%	31%	55%	59%	25%	56%
China 2019	83%	59%	58%	83%	57%	25%	64%
China 2020 †	67%	62%	46%	86%	68%	21%	58%
China 2024	95%	79%	81%	98%	48%	68%	78%
Cook Islands	52%	45%	24%	40%	61%	18%	42%
Japan 2019	100%	90%	97%	93%	82%	100%	94%
Japan 2023	98%	74%	84%	95%	29%	100%	64%
Korea	96%	83%	87%	73%	70%	87%	82%
Malaysia	100%	90%	90%	98%	75%	75%	90%
Republic of Marshall Islands	57%	79%	31%	36%	46%	25%	48%
New Zealand	67%	71%	37%	50%	66%	29%	64%
Philippines	100%	88%	90%	74%	66%	32%	77%
Samoa	72%	60%	52%	46%	65%	36%	55%
Singapore	91%	91%	75%	98%	61%	29%	77%

^† Only one reviewer performed quality appraisal.

Discussion

This review included 16 T2D CPGs from about one‐third of the Western Pacific region. All but one CPG included one or more medication management recommendations specific to older adults, dementia, frailty, or end‐of‐life care. Recommendations often related to minimizing ADEs and individualizing treatment. Nevertheless, there remains considerable scope for further consideration of these populations in future T2D CPGs.

The most frequent recommendations related to less stringent glycemic targets ranging from 7% to 8.1% depending on functional status, which is consistent with current evidence. ³² Glycemic targets for older adults, dementia, frailty and end‐of‐life care are reported in North American and European CPGs. ³³ , ³⁴ Glycemic targets in Western Pacific CPGs may have been adapted from international CPGs. Guideline adaptation allows limited resources to be directed towards implementation. ³⁵ However, it was unclear whether the glycemic targets in the Western Pacific were adapted for the local context. For example, in some low‐income and remote areas, regular access to blood glucose monitors and pathology testing may be unrealistic. ³⁶ Thus, it is unknown to what extent these recommendations are followed throughout the region.

Three CPGs recommended that older adults should have the same first‐line antihyperglycemics as younger adults21, 25, 26 with two additional CPGs ²⁰ , ²⁷ specifically recommending metformin. Countries in which these recommendations were included ranged from remote low–middle‐ to high‐income countries, which reflects metformin's favorable safety profile, availability and cost. ³² DPP4is, GLP‐1ras or SGLT‐2is were recommended in CPGs from Australia, China, Japan, Korea, New Zealand, and Samoa when older adults have contraindications to metformin, renal failure, hepatic failure, or CVD. These recommendations align with evidence supporting the benefits of GLP‐1ra and SGLT‐2i on all‐cause mortality in CVD and their reno‐protective properties, and the high prevalence of renal failure and CVD in the majority of these countries. ³⁷ , ³⁸ However, there is a high prevalence of CVD and renal failure in countries whose CPGs have yet to incorporate these recommendations, potentially owing to these being more than 5 years old. One Japanese CPG recommended against SGLT‐2is in those aged 75+ owing to dehydration and falls risk, ²⁴ and the 2024 Chinese CPG highlighted the need for individualized treatment for frailty, which reflects recent studies that have reported the need for a personalized treatment approach dependent on the phenotype of frailty the individual expresses, for example the sarcopenic obese or anorexic malnourished phenotype. ³⁹ , ⁴⁰ GLP‐1ras are not on the WHO Essential Medicines List. ⁴¹ This means that some countries may have limited access. The Samoan CPG includes recommendations for GLP‐1ras but acknowledges possible lack of access. Despite insulin and certain sulfonylureas being high‐risk or potentially inappropriate in older adults,⁴² 11 CPGs did not recommend or caution against these antihyperglycemics in older adults and in those living with dementia, frailty or receiving end‐of‐life care.

The lack of CPG recommendations has been reported as a barrier to deprescribing. ⁴³ Deprescribing recommendations were predominantly included in CPGs from upper‐middle‐ and high‐income countries, including Australia, China, Japan, Singapore, Malaysia, and New Zealand. The absence of deprescribing recommendations in other Western Pacific CPGs may reflect a greater focus on improving prevention, treatment, and medication adherence strategies, particularly in lower‐income countries where undertreatment is a concern. ¹¹ Although deprescribing has been shown to be safe and effective in older adults for reducing the risk of ADEs such as hypoglycemia and mortality, limited resources for CPG development may result in deprescribing recommendations being viewed as a lower priority for inclusion. ¹¹ , ⁴⁴

Failure to report conflicts of interest or funding statements contributed to the low editorial independence ratings in nine (56%) CPGs. However, omittance did not necessarily indicate conflicts of interest. In the past, 88% of CPGs in China have not declared conflicts of interest. ⁸ , ⁴⁵ This could be because the funding source was implied (i.e., when developed by the Government). Additionally, smaller countries with a limited number of specialists (e.g., endocrinologists, geriatricians) may not be able to recruit expert Guideline Development Group members without actual or perceived conflicts of interest. Rigor of development was rated low in CPGs that did not follow an established guideline development methodology such as GRADE. Around half (46%) of the countries or areas in the Western Pacific region are lower‐middle‐income countries,³¹ and developing CPGs through these methodologies is time‐ and resource‐intensive. Therefore, without the appropriate supports it may not always be achievable for CPGs of lower‐middle‐income countries to rate highly using the AGREE II tool. While AGREE II ratings reflected similarly to previous reviews of T2D CPGs (with low‐to‐middle‐income countries generally rated lower than higher‐income countries), ⁴⁶ , ⁴⁷ CPGs from high‐socioeconomic countries also rated low in these domains, which may stem from varying levels of CPG governance between countries.

This is the first systematic review focused on Western Pacific CPGs for any disease state. This focus allowed for consideration of demographics that may contribute to trends observed within recommendations. Not limiting for English allowed the inclusion of CPGs in Chinese and Japanese. Despite the comprehensive search strategy, it is possible that we did not identify all available CPGs. While we did not exclude based on language, searches were performed in English. We aimed to overcome this limitation through contacting relevant organizations where CPGs were not identified. The International Diabetes Federation (IDF) global guideline for managing older people with T2D was not included, as it is a global guideline and it was not known which countries may use this CPG in practice. ⁴⁸ Quality appraisal was only performed by one reviewer for one CPG in Chinese. Additionally, the term frailty may not be used in all countries; to mitigate against this limitation, we extracted recommendations for co‐morbidities associated with aging that often contribute to frailty.

Lack of recommendations specific to older adults within the Western Pacific region may be due to multiple factors. According to the IDF, the Western Pacific has an estimated 53% of adults with undiagnosed diabetes. ² Therefore, priorities within previous CPGs may have been directed toward screening, detection, and initial treatment of T2D. ³¹ , ³⁶ As the burden and age of the T2D population increases, disparities in T2D care will continue to rise, especially in vulnerable populations. ¹¹ Therefore, there may not be a “one‐size‐fits‐all” approach within the region, but greater awareness is required for increasing T2D medication management recommendations for older adults. Future CPGs can be improved by collaboration between government bodies, diabetes agencies, and geriatric societies. For example, CPGs developed for older adults from China and Japan adopted this model, which resulted in more detailed and comprehensive recommendations. ²¹ , ²⁴ Greater transparency and collaboration in CPG development between high‐income and lower‐middle‐income countries may improve the content and quality of CPGs. This was shown when New Zealand assisted in the development of the Samoan CPG. ²⁹ Enhanced communication in the region, such as reporting CPGs in development through registries such as GIN, may facilitate adaptations of CPGs that are relevant to the local context and assist in building capacity for CPG development in countries where health research or resources may be limited. One CPG from Australia is a living evidence guideline; this format could be implemented more widely to improve and update capability and streamline revisions. ¹⁷

Conclusion

While almost all Western Pacific CPGs included one or more recommendations for older adults, none of them comprehensively addressed the T2D medication management needs of older adults, those living with dementia, frailty, or receiving end‐of‐life care. CPG development in the region requires a nuanced approach that takes into consideration the variety of health challenges facing the area. Collaboration between diabetes and geriatric societies as well as higher‐income countries assisting those with less resource availability could provide a way forward to improving future CPGs.

Disclosure statement

All authors declare no competing interests. JSB has received grant funding or consulting funds from the National Health and Medical Research Council (NHMRC), Medical Research Future Fund, Victorian Government Department of Health and Human Services, Dementia Australia Research Foundation, Yulgilbar Foundation, Aged Care Quality and Safety Commission, Dementia Centre for Research Collaboration, Pharmaceutical Society of Australia, Society of Hospital Pharmacists of Australia, GlaxoSmithKline Supported Studies Programme, Amgen, and several aged care provider organizations unrelated to this work. All grants and consulting funds were paid to the employing institution. ER receives honoraria for co‐authoring a chapter on deprescribing in UpToDate and an honorarium from the Society of Hospital Pharmacists of Australia (leading workshops on deprescribing). ER is supported by a NHMRC Investigator Grant (GNT1195460). SH was partly supported by the Japan Society for the Promotion of Science (JSPS) KAKENHI (grant number JP22 K10406). The funding source had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.

Authors contributions

Darshna Goordeen: conceptualization, methodology, literature search, figures, study design, data collection and screening, data extraction, data verification, data analysis, data interpretation, writing – original draft and edits, project administration, reviewing and editing, approval and agreement of final version. Emily Reeve: supervision, conceptualization, methodology, study design, data verification, data interpretation, validation, reviewing and editing, approval and agreement of final version. J Simon Bell: supervision, conceptualization, methodology, study design, data verification, data interpretation, validation, reviewing and editing, approval and agreement of final version. Youmna Elsedfy: data screening, data extraction, data interpretation, data verification, reviewing and editing, approval and agreement of final version. Soroush Fariman: data extraction, data interpretation, writing reviewing and editing, approval and agreement of final version. Shota Hamada: data collection, data extraction, data interpretation, reviewing and editing, approval and agreement of final version. Yukari Hattori: data extraction, data interpretation, reviewing and editing, approval and agreement of final version. Kate Wang: data collection, data extraction, data interpretation, reviewing and editing, approval and agreement of final version. Majd Abu Al Shieh: data screening, reviewing and editing, approval and agreement of final version. Michael Nunan: data interpretation, reviewing and editing, approval and agreement of final version. Joshua Niznik: conceptualization, reviewing and editing, approval and agreement of final version. All authors had full access to the data and approved the final version of manuscript for publication.

Supporting information

Data S1 Supporting Information.

Table S1 Search strategy for Ovid MEDLINE.

Table S2. Data extraction table for recommendations.

Goordeen D, Bell JS, Elsedfy Y, et al. Diabetes medication management recommendations for older adults: A systematic review of the Western Pacific region. Geriatr. Gerontol. Int. 2025;25:717–729. 10.1111/ggi.70037

Data Availability Statement

The data that supports the findings of this study are available in the supplementary material of this article.