New Rosiglitazona

Clin Geriatr Med 24 (2008) 541–549

Oral Diabetic Medications and the Geriatric Patient
Alan B. Silverberg, MD, FACP, FACEa,*, Kenneth Patrick L. Ligaray, MDb
a

Division of Endocrinology, Department of Internal Medicine, Saint Louis University School of Medicine, 1402 South Grand Boulevard, St. Louis, MO 63104, USA b UAB Health Center Montgomery, University of Alabama School of Medicine,4371 Narrow Lane Road, Suite 200, Montgomery, AL 36116, USA

Approximately 7% of the United States population have diabetes mellitus, and the vast majority (90%–95%) have Type II diabetes [1]. Diabetes mellitus is an expensive, chronic, sometimes debilitating, disease. According to a recent study in Diabetes Care [2], Americans will spend $174 billion dollars annually on diabetes care. Twentypercent of health care dollars are spent for individuals diagnosed with diabetes mellitus [2]. The prevalence of diabetes mellitus increases with increasing age. Approximately 21% of people above the age of 60 in the United States have diabetes mellitus [3]. Clinical trials have provided evidence for the necessity of tight glycemic control to prevent microvascular and possibly macrovascularcomplications of diabetes [4–7]. How tight the glycemic control should be is not agreed upon by all the professional organizations in endocrinology and diabetes. For example, the American Association of Clinical Endocrinologists (AACE) recommends a hemoglobin A1c (HbA1c) of 6.5% or less [8]. The American Diabetes Association (ADA) recommends an HbA1c goal of 7% or less [9]. Similarly, the Canadian DiabetesAssociation (CDA) recommends individualized targets, but says that most patients should have an HbA1c of 7% or less [10]. Should these recommendations apply to all geriatric patients? The American Geriatric Society (AGS) recommends an HbA1c of 7% or less if the individual is healthy and has a good functional status, but 8% or less if the individual is frail and has a short life expectancy [11].* Corresponding author. E-mail address: silverab@slu.edu (A.B. Silverberg). 0749-0690/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.cger.2008.03.012 geriatric.theclinics.com

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The ACCORD trial (Action to Control Cardiovascular Risk in Diabetes) is a National Institutes of Health (NIH)-sponsored study of adults, aged 40 to 79years, who had Type II diabetes mellitus and a high risk of developing cardiovascular disease. Part of the trial was to determine whether tight glucose control (HbA1c of less than 6%) would decrease cardiovascular endpoints. It was recently reported that there were increased deaths in the intensively treated group (goal for the HbA1c less than 6%) compared with the less-intensive glucose control group(goal for the HbA1c 7–7.9%). The intensive treatment group had 257 deaths and the less-intensive treatment group had 203 deaths. To date an analysis of the study data has not been published, but the intensive glucose treatment arm of the study has been stopped (www.accordtrial.org). Glucose control, fasting and postprandial glucoses, should be as low as feasible without causing significant adverseevents such as hypoglycemia. Hypoglycemia in the elderly might lead to cardiac problems such as angina or myocardial infarctions, falls, fractures, and disability, and subsequent frailty. What are the current oral medications available for the management of diabetes mellitus in elderly individuals? Sulfonylurea medications Sulfonylureas are all generic medications, which makes them inexpensivedrugs for the management of Type II diabetes mellitus. They are insulin secretagoges that in some cases have been available for use for decades. They are typically divided into two groups, first-generation and second-generation medications. The first-generation sulfonylureas are chlorpropamide, acetoheximide, tolbutamide, and tolazamide. The main difference within each group is duration of action....