Table 4.
Special aspects of hypoglycaemic therapy in frail older people with diabetes
| Agent | Benefits | Cautions | Effect on frailty |
|---|---|---|---|
| Non-hypoglycaemia inducing agents | |||
| Metformin | Low risk of hypoglycaemia, CV protection | Lactic acidosis in patients with sepsis, organ dysfunction or dehydration. Some GI side effects. May cause vitamin B12 deficiency | May reduce the risk of frailty |
| DPP-4 inhibitors | Low risk of hypoglycaemia, well tolerated | GI side effects, some agents require dose adjustment in CKD, other agents may increase hospitalisation due to HF. cautions in patients with history of pancreatitis | May have a positive effect on muscle blood supply and reduction of sarcopenia |
| Acarbose | Low risk of hypoglycaemia may have some CV benefits | Less tolerated, GI side effects, weak hypoglycaemic effect | No data for effect on frailty |
| SGLT-2 | Low risk of hypoglycaemia, CV and renal protection | Risk of UTI, hypotension, dehydration and candidiasis. May be associated risk of fractures and DKA | Little data, it may improve muscle quality but this not confirmed |
| GLP-1RA | Low risk of hypoglycaemia, CV and renal protection | GI side effects, injectable, cautions in patients with history of pancreatitis. May be associated with thyroid C-cell tumours | Little and inconsistent data |
| Glitazones | Low risk of hypoglycaemia, have some CV protection, suitable in CKD | Increased fluid retention, exacerbation of HF, possible increased risk of fracture and bladder cancer | May have a positive effect on muscle mass and sarcopenia |
| Hypoglycaemia-inducing agents | |||
| Insulin secretagogues | Suitable in patients with CKD | High risk of hypoglycaemia | May be associated with increased risk of muscle atrophy |
| Insulin | Most potent hypoglycaemic agent, suitable in patients with organ dysfunction | High risk of hypoglycaemia, injectable and burden of blood glucose monitoring | Anabolic effect may improve muscle mass but further research still required |
CV Cardiovascular, GI Gastrointestinal, DPP-4 Dipeptidyl peptidase, CKD Chronic kidney disease, HF Heart failure, SGLT-2 Sodium glucose transporter, GLP-1RA glucagon like peptide-1 receptor agonists, UTI Urinary tract infection, DKA Diabetic ketoacidosis