Table 3.

Preferred medical therapy in elderly with diabetes

General approach

While diagnostic criteria are similar for adults of all ages, glycemic targets may be relaxed for the elderly

Follow the same hierarchy of choosing a glucose-lowering therapy as recommended for younger adults

Non-insulin drugs

Metformin is the drug of choice along with lifestyle modification, provided it is not contraindicated and is well tolerated

DPP4 inhibitors are preferred owing to the lower risk of hypoglycemia

Modern sulfonylurea may be used in low doses. Glibenclamide should be avoided

Pioglitazone should be avoided because of the risk of fractures and heart failure

SGLT2 inhibitors may be used in otherwise healthy persons with adequate nutrition and hydration while keeping vigilance for complications

GLP1RA may be used, provided the injectable therapy is accepted and tolerated

Insulin therapy

The indications for insulin are similar in adults of all age groups

If basal insulin is required, prefer preparations with a lower risk of hypoglycemia and nocturnal hypoglycemia, such as degludec and U300 glargine

If prandial coverage is necessary, prefer premixed insulin analogues or coformulations with a lower risk of hypoglycemia and nocturnal hypoglycemia, e.g., biphasic aspart, biphasic lispro, insulin degludec aspart

Low mixtures should be preferred over high mixtures

Once-daily regimens should be preferred over twice-daily regimens

Pen devices should be preferred over syringes and vials for insulin delivery