ТЕРАПИЯ САХАРНОГО ДИАБЕТА 2 ТИПА У ПОЖИЛЫХ ПАЦИЕНТОВ: РИСКИ И ПЕРСПЕКТИВЫ


https://doi.org/10.17709/2409-2231-2017-4-4-12

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Аннотация

Терапия сахарного диабета у пожилых пациентов представляет собой сложную задачу, обусловленную их гетерогенной популяцией, высоким риском гипогликемических состояний, развития жизнеопасных аритмий и сердечно-сосудистых заболеваний, деменции, наличием большого количества коморбидных заболеваний. Число пожилых пациентов в мире растет быстрыми темпами, тем не менее, алгоритма их лечения пока не разработано и предпочтение отдается индивидуальному подходу к терапии нарушений углеводного обмена. Не определены терапевтические цели у пожилых пациентов в зависимости от их клинических и функциональных особенностей, рекомендованный уровень гликированного гемоглобина варьирует в широком диапазоне — от 7 до 9%. Приоритетной остается задача профилактики гипогликемий, способных привести к фатальным последствиям. Требования к применению пероральных сахароснижающих препаратов у пожилых пациентов с сахарным диабетом сводятся также к отсутствию нефро-, гепатои кардиотоксичности, а также отсутствию у них взаимодействия с другими препаратами и удобству применения. Таким условиям отвечает инкретиновая терапия, представленная агонистами глюкагоноподобного пептида-1 и ингибиторами дипептидилпептидазы-4. Возможно также применение инсулинов ультрадлительного действия. Нежелательно применение у пожилых пациентов препаратов сульфонилмочевины и интенсивной инсулинотерапии. При отсутствии противопоказаний допустимо использование метформина и пиоглитазона, с большой осторожностью рекомендуется применение ингибиторов SGLT-2. Лечение любыми лекарственными сахароснижающими препаратами возможно у пожилых пациентов, ведущих активный образ жизни и способных к самоконтролю углеводного обмена, но у больных с низкой социальной адаптацией желательно ограничиться инкретиновой терапией.


Об авторе

Л. Ю. Моргунов
Медицинский институт РУДН
Россия

Моргунов Леонид Юльевич доктор медицинских наук, профессор кафедры  госпитальной  терапии  с курсом эндокринологии,  гематологии  и клинической лабораторной диагностики.

117198, Москва, ул. Миклухо-Маклая, д. 6



Список литературы

1. Алгоритмы специализированной медицинской помощи больным сахарным диабетом. Под редакцией И. И. Дедова. 8-й выпуск. М., 2017, 112 с./Algoritmy spetsializirovannoi meditsinskoi pomoshchi bol’nym sakharnym diabetom [Algorithms of specialized medical care for patients with diabetes mellitus]. Ed by I. I. Dedov. 8th ed. Мosocw, 2017, 112 p. (In Russian).

2. Gómez Huelgas R, Díez-Espino J, Formiga F, Lafita Tejedor J, Rodríguez Mañas L, González-Sarmiento E, Menéndez E, Sangrós J. Treatment of type 2 diabetes in the elderly. Med Clin (Barc). 2013 Feb 2;140 (3): 134.e1–134.e12. DOI: 10.1016/j.medcli.2012.10.003

3. Pratley RE, Heller SR, Miller MA. Treatment of type 2 diabetes mellitus in the older adult: a review. Endocr Pract. 2014 Jul;20 (7):722–36. DOI: 10.4158/EP13192.RA

4. Abbatecola AM, Paolisso G, Sinclair AJ. Treating diabetes mellitus in older and oldest old patients. Curr Pharm Des. 2015; 21 (13): 1665–71. DOI: 10.2174/1381612821666150130120747

5. Budyono C, Setiati S, Purnamasari D, Rumende CM. The Proportion of Orthostatic Hypotension and Its Relationship with HbA1c Levels in Elderly Patients with Diabetes. Acta Med Indones. 2016 Apr; 48 (2): 122–8. http://www.inaactamedica.org/archives/2016/27550881.pdf

6. Mitrakou A, Katsiki N, Lalic NM. Type 2 Diabetes Mellitus and the Elderly: An Update on Drugs Used to Treat Glycaemia. Curr Vasc Pharmacol. 2017; 15 (1): 19–29. DOI: 10.2174/1570161114666160822154816

7. Johnston SS, Conner C, Aagren M, Smith DM, Bouchard J, Brett J. Evidence linking hypoglycemic events to an increased risk of acute cardiovascular events in patients with type 2 diabetes. Diabetes Care. 2011 May;34 (5):1164–70. DOI: 10.2337/dc10–1915.

8. Whitmer RA, Karter AJ, Yaffe K, Quesenberry CP Jr, Selby JV. Hypoglycemic episodes and risk of dementia in older patients with type 2 diabetes mellitus. JAMA. 2009 Apr 15;301 (15):1565–72. DOI: 10.1001/jama.2009.460

9. Abbatecola AM, Maggi S, Paolisso G. New approaches to treating type 2 diabetes mellitus in the elderly: role of incretin therapies. Drugs Aging. 2008;25 (11):913–25. DOI: 10.2165/0002512–200825110–00002

10. Hanefeld M, Ganz X, Nolte C. Hypoglycemia and cardi ac arrhythmia in patients with diabetes mellitus type 2. Herz. 2014 May;39 (3):312–9. doi: 10.1007/s00059–014–4086–1

11. Sircar M, Bhatia A, Munshi M. Review of Hypoglycemia in the Older Adult: Clinical Implications and Management. Can J Diabetes. 2016 Feb; 40 (1): 66–72. DOI: 10.1016/j.jcjd.2015.10.004

12. Nguyen HT, Arcury TA, Grzywacz JG, Saldana SJ, Ip EH, Kirk JK, et al. The association of mental conditions with blood glucose levels in older adults with diabetes. Aging Ment Health. 2012;16 (8):950–7. DOI: 10.1080/13607863.2012.688193

13. Nandipati S, Luo X, Schimming C, Grossman HT, Sano M. Cognition in non-demented diabetic older adults. Curr Aging Sci. 2012; 5 (2): 131–5. DOI: 10.2174/1874609811205020131

14. Boels AM, Hart HE, Rutten GE, Vos RC. Personalised treatment targets in type 2 diabetes patients: The Dutch approach. Prim Care Diabetes. 2017 Feb; 11 (1): 71–7. DOI: 10.1016/j.pcd.2016.08.00

15. Pratley RE, Gilbert M. Clinical management of elderly patients with type 2 diabetes mellitus. Postgrad Med. 2012 Jan;124 (1):133–43. DOI: 10.3810/pgm.2012.01.2526

16. American Diabetes Association Standards of medical care in diabetes — 2012. Diabetes Care. 2012;35 (Suppl 1): S11-S63.

17. American Diabetes Association Standards of medical care in diabetes — 2013. Diabetes Care. 2013; 36 (Suppl 1): S11–S66. DOI: 10.2337/dc13-S011

18. Lee SJ, Boscardin WJ, Stijacic CI, Huang ES, Rice-Trumble K, Eng C. The risks and benefits of implementing glycemic control guidelines in frail older adults with diabetes mellitus. J Am Geriatr Soc. 2011 Apr;59 (4):666–72. DOI: 10.1111/j.1532–5415.2011.03362.x.

19. VA/DoD clinical practice guideline for the management of diabetes mellitus. Version 4.0. Washington, DC: Veterans Health Administration and Department of Defense; 2010.

20. Ismail-Beigi F, Moghissi E, Tiktin M, Hirsch IB, Inzucchi SE, Genuth S. Individualizing glycemic targets in type 2 diabetes mellitus: implications of recent clinical trials. Ann Intern Med. 2011 Apr 19;154 (8):554–9. DOI: 10.7326/0003–4819–154–8-201104190–00007.

21. Sinclair A, Morley JE, Rodriguez-Manas L, Paolisso G, Bayer T, Zeyfang A, et al. Diabetes mellitus in older people: position statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People (EDWPOP), and the International Task Force of Experts in Diabetes. J Am Med Dir Assoc. 2012 Jul;13 (6):497–502. DOI: 10.1016/j.jamda.2012.04.012.

22. Major K, Saiah L, Rubli E, Rochat S, Monod S, Büla C. Review in geriatric medicine 2012. Rev Med Suisse. 2013 Jan 9; 9 (368): 40–3.

23. Mitrakou A, Katsiki N, Lalic NM. Type 2 Diabetes Mellitus and the Elderly: An Update on Drugs Used to Treat Glycaemia. Curr Vasc Pharmacol. 2017; 15 (1): 19–29. DOI: 10.2174/1570161114666160822154816

24. Pratley RE, Gilbert M. Clinical management of elderly patients with type 2 diabetes mellitus. Postgrad Med. 2012 Jan;124 (1):133–43. DOI: 10.3810/pgm.2012.01.2526

25. Deletre S, Coutaz M. Diabetes: glycemic targets and over-treatment in older patients. Rev Med Suisse. 2016 Mar 2;12 (508):461–4, 466

26. Thompson AM, Linnebur SA, Vande Griend JP, Saseen JJ. Glycemic targets and medication limitations for type 2 diabetes mellitus in the older adult. Consult Pharm. 2014 Feb; 29 (2): 110–23. DOI: 10.4140/TCP.n.2014.110

27. Zeyfang A. Individualized diabetes therapy in older persons]. Internist (Berl). 2016 May; 57 (5): 502–7. DOI: 10.1007/s00108–016–0039–5

28. Bramlage P, Gitt AK, Binz C, Krekler M, Deeg E, Tschöpe D. Oral antidiabetic treatment in type-2 diabetes in the elderly: balancing the need for glucose control and the risk of hypoglycemia. Cardiovasc Diabetol. 2012 Oct 6;11:122. DOI: 10.1186/1475–2840–11–122

29. Bodmer M, Meier C, Krahenbuhl S, Jick SS, Meier CR. Metformin, sulfonylureas, or other antidiabetes drugs and the risk of lactic acidosis or hypoglycemia: a nested case-control analysis. Diabetes Care. 2008 Nov;31 (11):2086–91. DOI: 10.2337/dc08–1171

30. Formiga F, Gómez-Huelgas R, Rodríguez Mañas L. Differential characteristics of type 2 diabetes in the elderly. Role of dipeptidyl peptidase 4 inhibitors. Rev Esp Geriatr Gerontol. 2016 JanFeb;51 (1):44–51. DOI: 10.1016/j.regg.2015.04.002

31. Freeman J. Hot Topics in Primary Care: Considerations in the Selection of Antihyperglycemic Therapy for Older Patients With Type 2 Diabetes Mellitus: A Focus on Newer Therapies. J Fam Pract. 2015 Dec;64 (12 Suppl): S59–66

32. Abbatecola AM, Paolisso G. Diabetes care targets in older persons. Diabetes Res Clin Pract. 2009 Dec;86 Suppl 1: S35–40. DOI: 10.1016/S0168–8227(09)70007–5

33. Germino FW. Noninsulin treatment of type 2 diabetes mellitus in geriatric patients: a review. Clin Ther. 2011 Dec; 33 (12): 1868–82. DOI: 10.1016/j.clinthera.2011.10.020

34. Fu H, Curtis BH, Schuster DP, Festa A, Kendall DM. Treatment patterns among older patients with type 2 diabetes in the United States: a retrospective cohort study. Diabetes Technol Ther. 2014 Dec; 16 (12): 833–9. DOI: 10.1089/dia.2014.0039

35. Abbatecola AM, Maggi S, Paolisso G. New approaches to treating type 2 diabetes mellitus in the elderly: role of incretin therapies. Drugs Aging. 2008;25 (11):913–25. DOI: 10.2165/0002512–200825110–00002

36. Clinicaltrials.gov. Study of Sitagliptin in Older Type 2 Diabetics (Clincal trial identifier NCT00305604), 2013

37. Fernández MA. Treatment of older persons with diabetes. Semergen. 2014 May;40 Suppl 1:10–6. DOI: 10.1016/S1138–3593(14)74382–5

38. Russell S. Incretin-based therapies for type 2 diabetes mellitus: a review of direct comparisons of efficacy, safety and patient satisfaction. Int J Clin Pharm. 2013 Apr;35 (2):159–72. DOI: 10.1007/s11096–012–9729–9

39. Bourdel-Marchasson I, Schweizer A, Dejager S. Incretin therapies in the management of elderly patients with type 2 diabetes mellitus. Hosp Pract (1995). 2011 Feb;39 (1):7–21. DOI: 10.3810/hp.2011.02.369

40. Halimi S, Raccah D, Schweizer A, Dejager S. Role of vildagliptin in managing type 2 diabetes mellitus in the elderly. Curr Med Res Opin. 2010 Jul;26 (7):1647–56. DOI: 10.1185/03007995.2010.485881

41. Tasci I, Naharci MI, Bozoglu E, Safer U, Aydogdu A, Yilmaz BF, et al. Cognitive and functional influences of vildagliptin, A DPP-4 inhibitor, added to ongoing metformin therapy in elderly with type 2 diabetes. Endocr Metab Immune Disord Drug Targets. 2013 Sep;13 (3):256–63. DOI: 10.2174/18715303113139990037

42. Barnett A, Huisman H, Jones R, et al. Efficacy and safety of Linagliptin in elderly patients (>/=70 Years) with type 2 diabetes [abstract 1017-P]. Diabetes. 2012;61: A260–A261.

43. Barzilai N, Guo H, Mahoney EM, Caporossi S, Golm GT, Langdon RB, et al. Efficacy and tolerability of sitagliptin monotherapy in elderly patients with type 2 diabetes: a randomized, double-blind, placebo-controlled trial. Curr Med Res Opin. 2011 May;27 (5):1049–58. DOI: 10.1185/03007995.2011.568059

44. Shankar R, Engel S, Xu L, et al. Sitagliptin provides similar glycemic improvement with less hypoglycemia in the elderly with type 2 diabetes mellitus compared to sulfonylurea. Diabetes. 2012;61: A278.

45. St Onge EL, Miller S, Clements E. Sitagliptin/metformin (Janumet) as combination therapy in the treatment of type-2 diabetes mellitus. Pharm Ther. 2012; 37 (12): 699–708.

46. Charbonnel B, Barnett A, Monyak J, et al. Efficacy and safety of saxagliptin in combination with insulin in elderly patients with type 2 diabetes [abstract 1048-P]. Diabetes. 2012; 61: A269.

47. Amori RE, Lau J, Pittas AG. Efficacy and safety of incretin therapy in type 2 diabetes: systematic review and meta-analysis. JAMA. 2007; 298 (2):194–206. DOI: 10.1001/jama.298.2.194

48. Pratley RE. Linagliptin use in older individuals with type 2 diabetes. Clin Interv Aging. 2014 Jul 16;9:1109–14. doi: 10.2147/CIA.S62877

49. Triplitt CL. Managing diabetes in patients with diabetes of long duration. Diabetes Educ. 2012 Jul-Aug;38 (4 Suppl):23S-30S; quiz 31S. DOI: 10.1177/0145721712449390

50. Pencek R, Blickensderfer A, Li Y, Brunell SC, Anderson PW. Exenatide twice daily: analysis of effectiveness and safety data stratified by age, sex, race, duration of diabetes, and body mass index. Postgrad Med. 2012 Jul;124 (4):21–32. DOI: 10.3810/pgm.2012.07.2567

51. Bode BW, Brett J, Falahati A, Pratley RE. Comparison of the efficacy and tolerability profile of liraglutide, a once-daily human GLP-1 analog, in patients with type 2 diabetes >/=65 and<65 years of age: a pooled analysis from phase III studies. Am J Geriatr Pharmacother. 2011 Dec;9 (6):423–33. DOI: 10.1016/j.amjopharm.2011.09.007

52. Raccah D, Miossec P, Esposito V, Niemoeller E, Cho M, Gerich J. Efficacy and safety of lixisenatide in elderly (>65 yr) and very elderly (>/=75 yr) patients with type 2 diabetes: an analysis from the GetGoal Phase 3 Program. Diabetes Metab Res Rev. 2015 Feb;31 (2):204–11. DOI: 10.1002/dmrr.2588

53. Rajagopalan R, Xu Y, Abbadessa M; Quartet Study Group. The effect of pioglitazone on glycemic and lipid parameters and adverse events in elderly patients with type 2 diabetes mellitus: a post hoc analysis of four randomized trials. Am J Geriatr Pharmacother. 2006 Jun;4 (2):123–33. DOI: 10.1016/j.amjopharm.2006.06.003

54. GLT2 inhibition in diabetes mellitus: rationale and clinical prospects. Nat Rev Endocrinol. 2012; 8:495–502. DOI: 10.1038/nrendo.2011.243.

55. Bode B, Stenlof K, Sullivan D, Fung A, Usiskin K. Efficacy and safety of canagliflozin treatment in older subjects with type 2 diabetes mellitus: a randomized trial. Hosp Pract (1995). 2013 Apr;41 (2):72–84. DOI: 10.3810/hp.2013.04.1020

56. Graillot D, Quipourt V, Bouillet B, Petit JM, Manckoundia P. Type 2 diabetes in the elderly, which specific features?. Rev Med Interne. 2012 Oct; 33 (10): 575–9. DOI: 10.1016/j.revmed.2012.06.001

57. Tanwani LK. Insulin therapy in the elderly patient with diabetes. Am J Geriatr Pharmacother. 2011 Feb;9 (1):24–36. DOI: 10.1016/j.amjopharm.2011.02.006

58. Zafon C, Creus C. A comparison on insulin regimen treatment of elderly (>70 years) and younger (<70 years) type 2 diabetic patients in actual clinical practice. Acta Diabetol. 2013 Feb;50 (1):33–7. DOI: 10.1007/s00592–011–0289–6.

59. Rodbard HW, Jellinger PS, Davidson JA, Einhorn D, Garber AJ, Grunberger G, et al. Statement by an American Association of Clinical Endocrinologists/American College of Endocrinology consensus panel on type 2 diabetes mellitus: an algorithm for glycemic control. Endocr Pract. 2009 Sep-Oct; 15 (6): 540–59. DOI: 10.4158/EP.15.6.540

60. Lee P, Chang A, Blaum C, Vlajnic A, Gao L, Halter J. Comparison of safety and efficacy of insulin glargine and neutral protamine hagedorn insulin in older adults with type 2 diabetes mellitus: results from a pooled analysis. J Am Geriatr Soc. 2012 Jan;60 (1):51–9. DOI: 10.1111/j.1532–5415.2011.03773.x

61. Garber AJ, Clauson P, Pedersen CB, Kølendorf K. Lower risk of hypoglycemia with insulin detemir than with neutral protamine hagedorn insulin in older persons with type 2 diabetes: a pooled analysis of phase III trials. J Am Geriatr Soc. 2007 Nov;55 (11):1735–40. DOI: 10.1111/j.1532–5415.2007.01414.x

62. Jonassen I, Havelund S, Hoeg-Jensen T, Steensgaard DB, Wahlund PO, Ribel U. Design of the novel protraction mechanism of insulin degludec, an ultra-long-acting basal insulin. Pharm Res. 2012 Aug;29 (8):2104–14. doi: 10.1007/s11095–012–0739-z

63. Ratner RE, Gough SCL, Mathieu C, Del Prato S, Bode B, Mersebach H, et al. Hypoglycaemia risk with insulin degludec compared with insulin glargine in type 2 and type 1 diabetes: a preplanned meta-analysis of phase 3 trials. Diabetes Obes Metab. 2013 Feb;15 (2):175–84. DOI: 10.1111/dom.12032.

64. Gough S, Ratner R, Mathieu C, Del Prato S, Bode B, Mersebach H, et al. Prospectively planned meta-analysis comparing hypoglycaemia rates of insulin degludec with those of insulin glargine in all patients and an elderly (>65 year) subgroup [poster]. European Association for the Study of Diabetes: October 1, 2012; Berlin, Germany.

65. Zinman B, Philis-Tsimikas A, Cariou B, Handelsman Y, Rod bard HW, Johansen T, et al. Insulin degludec versus insulin glargine in insulin-naive patients with type 2 diabetes: a 1-year, randomized, treat-to-target trial (BEGIN Once Long). Diabetes Care. 2012 Dec;35 (12):2464–71. DOI: 10.2337/dc12–1205

66. Abbatecola AM, Paolisso G, Corsonello A, Bustacchini S, Lattanzio F. Antidiabetic oral treatment in older people: does frailty matter? Drugs Aging. 2009 Dec;26 Suppl 1:53–62. DOI: 10.2165/11534660–000000000–00000.

67. Neumiller JJ, Setter SM. Pharmacologic management of the older patient with type 2 diabetes mellitus. Am J Geriatr Pharmacother. 2009 Dec; 7 (6): 324–42. DOI: 10.1016/j.amjopharm.2009.12.002

68. Asche CV, McAdam-Marx C, Shane-McWhorter L, Sheng X, Plauschinat CA. Evaluation of adverse events of oral antihyperglycemic monotherapy experienced by a geriatric population in a real-world setting: a retrospective cohort analysis. Drugs Aging. 2008; 25 (7): 611–22.


Дополнительные файлы

Для цитирования: Моргунов Л.Ю. ТЕРАПИЯ САХАРНОГО ДИАБЕТА 2 ТИПА У ПОЖИЛЫХ ПАЦИЕНТОВ: РИСКИ И ПЕРСПЕКТИВЫ. Исследования и практика в медицине. 2017;4(4):110-124. https://doi.org/10.17709/2409-2231-2017-4-4-12

For citation: Morgunov L.Y. THERAPY OF TYPE 2 DIABETES MELLITUS IN ELDERLY PATIENTS: RISKS AND PROSPECTS. Research'n Practical Medicine Journal. 2017;4(4):110-124. (In Russ.) https://doi.org/10.17709/2409-2231-2017-4-4-12

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