Type 2 diabetes (DM2) is a disease characterized by the onset of chronic hyperglycemia due to the inability of pancreatic beta cells to produce a sufficient quantity of insulin to compensate for the patient’s insulin resistance.1 The progressive aging of the population has resulted in an increase in the prevalence of DM2, which can reach over 20% in the elderly population (defined as those older than 65 years).2

DM2 in elderly patients is due to a combination of insulin resistance (promoted by adiposity, sarcopenia and physical inactivity) and a progressive loss in the capacity to secrete insulin.3 Beta-cell replication potential decreases due to the accumulation of DNA mutations with age.4 Nevertheless, people with DM2 who are older than 65 years are heterogeneous, given that some have a recent diagnosis of the disease and others have had the disease for a long time. As age progresses, the prevalence of vascular complications, cognitive impairment and frailty increases.3

The main factor responsible for the onset of chronic complications is the patient’s overall glycemic exposure, defined as the degree of hyperglycemia multiplied by the duration of the condition. Meta-analyses that have evaluated the efficacy of intensive blood glucose control in patients with DM2 have shown reductions in microcomplications.5 Although more modest, reductions in macrovascular complications6 have also been shown in 5 and 10-year periods. Nevertheless, to observe significant reductions in mortality, follow-ups longer than 10 years are needed, as are interventions for patients who have recently contracted the disease.7,8 In recent years, numerous cardiovascular safety trials have been published, which have changed clinical practice by demonstrating the additional benefits of a number of drugs (glucagon-like peptide-1 receptor [GLP-1] agonists and sodium-dependent glucose cotransporter 2 inhibitors [SGLT2i]) beyond their effect on blood glucose control.9

The long-term benefit of good blood glucose control should be weighed against the increased risk of hypoglycemia, Which occurs more frequently in elderly individuals (especially in the presence of chronic kidney disease or cognitive impairment) and is associated with increased total and cardiovascular mortality.10 It is worth noting that metformin, glitazones, dipeptidyl peptidase 4 inhibitors (DPP4i), GLP-1 agonists and SGLT2i do not induce the onset of hypoglycemia.

In this issue of the journal, Gómez Huelgas et al.11 report on the results of a cross-sectional descriptive study that assessed the appropriateness of hypoglycemic treatment in patients with DM2 older than 65 years. The data was collected during 2014, with the participation of 450 specialized care and 2100 primary care physicians. An appropriate treatment was considered when it complied with the recommendations, published in 2013, of the consensus of the Spanish Society of Internal Medicine (SEMI), Spanish Society of Diabetes (SED), Spanish Society of Geriatric Medicine (SEMEG and SEGG) and the Spanish Network of Diabetes Study Groups in Primary Health Care (redGDPS). These recommendations prioritize drug treatment with metformin as the first step and treatment with metformin plus DPP4i as the second step. The study included almost 5000 patients, with a mean age of 73 years, 25.9% of whom were at risk of severe hypoglycemia and 9.4% of whom had a history of previous episodes of hypoglycemia. The main findings were that only 14.6% of the patients met the recommended protocol and that more than half of those at risk of severe hypoglycemia underwent treatment with secretagogues or insulin. In the authors’ opinion, better compliance is needed by practitioners to the recommendations of the clinical practice guidelines, as well as a preferential use of drugs with a low risk of hypoglycemia for elderly patients.

Monitoring the application in standard clinical practice of the guidelines’ recommendations is essential. The guidelines are unanimous12–14 in that the treatment of DM2 needs to be individualized for elderly patients, with control objectives between 7% and 8.5% depending on life expectancy, the functional situation and risk of hypoglycemia. The authors also emphasize the need to prioritize drugs that have shown a cardiovascular benefit and that do not induce hypoglycemia or adverse effects. As the elderly patient’s functional state worsens, the recommendation is to simplify the therapeutic regimen, with DPP4i an attractive group due to their good tolerance.

The study by Gómez Huelgas et al.11 obtained the participation of a large number of researchers, which increased the study’s representativeness. Those researchers also conducted an assessment of the patients’ hypoglycemia risk, which helped determine that half of the patients at risk for severe hypoglycemia were treated with drugs that could induce hypoglycemia. Given that the use of insulin can become essential, the most worrying fact was that 25% of these patients were treated with sulfonylureas or glinides, drugs easily substitutable by other safer drugs.

The study’s main limitation, as recognized in the article’s Discussion section, is that the therapeutic guidelines have been updated since 2013. Nevertheless, the recommendation still advises to adjust the blood glucose objectives to the patients’ age, functional state and concomitant diseases, as is the recommendation for preventing hypoglycemia. Therefore, the authors’ final message that elderly patients with DM2 should receive drugs with a low risk of hypoglycemia remains valid.

The progressive increase in the prevalence of elderly individuals with DM2 and the increase in therapeutic options for controlling DM2 requires individualization of the treatment to achieve the best risk-benefit ratio.15 It is our job to intensify or deintensify the treatment for elderly patients, adapting the treatment at all times to their functional state and life expectancy.