Managing type 2 diabetes is not a “one-size fits all” or “set it and forget it” condition. Rather, due to the natural history and diversity in presentation of the disease, treatment should be a continuously adapting and dynamic process between you and your provider.
The need to adjust your diabetes treatment regimen over time stems from the effect diabetes has on your body. While various lifestyle modifications such as diet, exercise, and weight loss may delay the progression of the condition (and in some cases induce remission) most people still require medication to maintain blood sugars in target ranges and prevent complications over time. There are dozens of medications available now including pills, injectable and inhaled insulin, and non-insulin injectable agents. When used appropriately, they can often prevent secondary health conditions like heart disease and chronic kidney disease from developing or progressing.
Over time, chronic and highly uncontrolled blood sugars can lead to complications later in life like hypoglycemia unawareness, vision changes, kidney failure, nerve pain and/or numbness, and skin disorders. However, we now know the causes of these complications from decades of research, and we also have better management tools like continuous glucose monitoring and more effective medication interventions, so treating diabetes has evolved from simply managing complications when they arise to preventing them altogether and delaying their progression.
The Natural Progression of Type 2 Diabetes
Even if you take your medications and follow your regimen exactly as prescribed from day one, there is a natural progression of type 2 diabetes (typically over years or decades) which necessitates medication shifts regardless of your adherence. Realizing this, a need for insulin, for example, should not be viewed as a personal failure, but rather understood in the context of the natural history of type 2 diabetes.
Adjusting A1c Targets
The hemoglobin A1c (HbA1c) level is one way your provider can measure the effectiveness of your diabetes management. According to the Standards of Medical Care in Diabetes, the American Diabetes Association advocates for the consideration of various criteria in determining an A1c target, such as risk for hypoglycemia, disease duration, age, other related health conditions, medication and lifestyle preferences, and support systems. Ideally, an A1c of less than 7% is desired to reduce risk of developing complications, however this value is generally relaxed with age (generally for those over age 65). The ultimate goal of management involves attaining blood sugars in a target range using the simplest and safest treatment plan. Success is seen typically when the treatment regimen is simple and easy to implement by the person living with diabetes.
Optimizing Your Diabetes Regimen
There are several factors to consider when you and your provider begin discussing an optimized regimen: your personal preferences, your other health conditions, your age, and medication costs.
- Personal Preferences
Medication adherence is a key component to a successful regimen, because medications are only effective if they’re taken as prescribed. If you’re having problems with a particular medication, it’s important for you to share this with your provider. It’s equally important for your provider to listen to your preferences so he or she can make appropriate medication recommendations. If you don’t like a medication that’s prescribed for you and you don’t take it, progress will not be made. Costs to you in terms of increased risk of complications, and fiscal cost to the health care system in terms of progression of disease should be considered. Route of administration, side effects, and cost (among other factors) must be discussed to enhance potential for adherence, especially as a regimen changes over time.
As we get older (particularly after age 65), we have an increased risk of developing age-related issues such as impaired vision, cognitive decline, and decreasing dexterity, which may limit the use of certain diabetes medications and devices. For instance, if you aren’t able to draw up insulin from a vial to the correct number of units, it would warrant switching to an alternative treatment such as insulin pens.
Risks of more serious complications associated with hypoglycemia may also increase with age. To combat this, A1c targets may be increased (i.e. less than 8%, as opposed to less than 7%) or medications associated with low blood sugar, such as insulin or sulfonylureas, may be discontinued or substituted for a diabetes medication with a lower or nonexistent risk of hypoglycemia.
- Reducing Medication Burden
Reducing medication burden or de-intensifying is another effective means of improving adherence in the elderly, such as using combined medications and replacing a four shot per day basal/bolus regimen with a single injection of a fixed-ratio combination, such as Soliqua 100/33 (insulin glargine and lixisenatide) or Xultophy (insulin degludec and liraglutide). Using such fixed-ratio medications as well is easy to administer without mixing, so there is little room for error. A daily injection of Soliqua, indicated for use in the morning in the hour prior to the first meal, can assist in reducing after-meal blood sugar elevations without the need for additional multi-dose meal-time insulin boluses.
Simplifying your regimen to reduce the risk of harm and improve adherence should be an important focus of management.
- Related Health Conditions and Side Effects
As discussed above, with age comes an increased risk for both diabetes-related complications and non-diabetes health conditions. Whenever possible, it is ideal to use medications that provide benefits for the greatest number of conditions. For example, GLP-1 receptor agonists (Trulicity, Ozempic, Victoza, Lixisenatide/Adlyxin, etc.) can benefit elderly patients by reducing blood sugar in a nutrient-dependent manner (thereby reducing the incidence of hypoglycemia) and several have been proven to concurrently reduce the risk of major cardiovascular events. A similar benefit can be seen with the use of SGLT2 inhibitors in people with diabetes and heart failure and/or renal disease.
Affordability becomes a major consideration in prescribed medications, particularly in aging populations as incomes may become reduced and fixed. In such cases, use of generic medications or formulary specific options may be used. However, ideally, when available, various manufacturers offer savings programs or coupons with set monthly copays to allow patients to access newer beneficial medications. The Medicare Senior Savings Program offers many benefits for seniors, including caps on medications like Soliqua for a $35 fixed monthly copy (and no coverage gap). You may review an insurance plan’s formulary when considering which plan to enroll in. As Medicare open enrollment is approaching (October 15- December 7), you can see if your plan is participating in the Medicare Senior Savings Program by entering your zip code and selecting the Part D plan on this page of Medicare.gov.
Throughout the course of your diabetes treatment, your medication requirements will most likely change. As you age, providers generally are less concerned with long-term complications from high blood sugars and are more concerned about lows and other side effects. Safety and simplicity become the main priorities. Over time, your current regimen may not remain ideal for you. Consider speaking to your doctor about simplifying your regimen to optimize your diabetes management, reduce your risk of low blood sugar, and decrease your medication costs.