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Scientific letter
Treatment of diabetes in the elderly. Is there anything to improve?
Tratamiento de la diabetes en el anciano. ¿Hay algo que mejorar?
Pedro J. Pinés-Corralesa,
Corresponding author
pjpines@sescam.jccm.es

Corresponding author.
, Pilar Ibáñez-Navarroa, Ángela Vicente-Albiñanaa, Gema Sáez-Valenciab
a Department of Endocrinology, Diabetes and Nutrition, Hospital General de Almansa, Spain
b Department of Pharmacy, Complejo Hospitalario Universitario de Albacete, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Diabetes in elderly people is one of the main problems for our Public Health System today&#46; Aging is causing a marked increase in the pandemic of diabetes and its prevalence in Spain for men and women older than 75 years-old is greater than 20&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> We know that the therapeutic strategies and targets should be individualized in these patients but scientific evidence to support the most appropriate treatment is scarce&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#8211;3</span></a> Metformin is the first-line agent and recent studies have indicated that it may be used safely in patients with estimated glomerular filtration rate &#40;eGFR&#41; &#8805;30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#46; However&#44; metformin is contraindicated in patients with advanced renal insufficiency&#46; Sulfonylureas are associated with hypoglycemia and should be used with caution in patients with increased susceptibility&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">4&#8211;5</span></a> Ruiz-Tamallo et al&#46; observed that a significant proportion of patients with eGFR &#60;30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> were on metformin or sulfonylureas treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> The aim of our study was to know if the use of metformin and sulfonylureas were lower in patients &#8805;75 years-old with eGFR &#60;45<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> and determine the prevalence of patients &#8805;75 years-old who are in treatment with metformin or sulfonylureas that have had eGFR &#60;30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> or without eGFR within the last year&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">From January 2017 to April 2017&#44; we identified in our pharmacological prescription program&#44; 1183 patients &#8805;75 years-old who were taking pharmacological treatment for diabetes &#40;insulin and no insulin&#41;&#46; These patients live among the three basic health areas located in the southeast of Castilla-La Mancha which attend a total of 41992 inhabitants&#46; 70&#46;4&#37; of them were treated with metformin and 14&#37; with sulfonylureas &#40;13 patients were on gliblenclamide treatment&#41;&#46; We analyzed a randomly selected sample of 295 patients &#40;calculated to have enough statistical power&#41; and the following variables were collected&#58; age &#40;years&#41;&#44; sex &#40;male or female&#41;&#44; pharmacological treatment for diabetes &#40;metformin&#44; sulfonylureas&#44; glinides&#44; thiazolidinediones&#44; DPP-4 inhibitors&#44; GLP-1 receptor agonist&#44; SGLT-2 inhibitors and insulin&#41;&#44; and the last blood analysis with A1c and eGFR in the previous year&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Data were analyzed with the use of G-Stat 2&#46;0 software&#46; Qualitative variables were expressed as an absolute and relative frequency&#46; Quantitative variables were expressed as a mean and standard deviation &#40;SD&#41;&#46; The Chi-square test was used to compare proportions of use of metformin or sulfonylureas between two groups &#40;eGFR &#60;45<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> vs&#46; eGFR &#8805;45<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#41;&#46; A <span class="elsevierStyleItalic">p</span> value &#60;0&#46;05 was considered statistically significant&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The mean age was 82&#46;7 years &#40;SD&#58; 5&#46;1&#41; and 106 patients &#40;35&#46;9&#37;&#41; were 85 years of age or older&#46; 173 patients &#40;58&#46;6&#37;&#41; were women&#46; 220 patients &#40;74&#46;6&#37;&#41; were on metformin&#44; 39 &#40;13&#46;2&#37;&#41; on sulfonylureas&#44; 18 &#40;6&#46;1&#37;&#41; on glinides and 99 &#40;33&#46;6&#37;&#41; on DPP-4 inhibitors&#46; Only 1 patient was treated with GLP-1 receptor agonist and 9 with SGLT-2 inhibitors&#46; 45 patients &#40;15&#46;2&#37;&#41; were on basal insulin analogs and 18 &#40;6&#46;1&#37;&#41; on premixed insulin&#46; Only 3 patients were treated with intermediate acting insulin &#40;Human NPH or NPL insulin&#41; and only 5 with basal-acting insulin more rapid-acting insulin&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The mean A1c was 7&#46;1&#37; &#40;SD&#58; 1&#46;2&#41; but only 190 patients &#40;64&#46;4&#37;&#41; had this result in the last year&#46; 47 patients &#40;15&#46;9&#37;&#41; did not have eGFR during the last year and 11 &#40;3&#46;7&#37;&#41; had eGFR &#60;30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#46; 153 patients &#40;51&#46;9&#37;&#41; had eGFR &#8805;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#44; 43 &#40;14&#46;6&#37;&#41; between 45 and 59<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> and 41 &#40;13&#46;9&#37;&#41; between 30 and 44<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Thirty five patients with eGFR &#60;45<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> &#40;67&#46;3&#37;&#41; were treated with metformin or sulfonylureas vs&#46; 168 patients with eGFR &#8805;45<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> &#40;85&#46;7&#37;&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;0079&#41;&#46; Forty two patients treated with metformin or sulfonylureas &#40;17&#46;5&#37;&#59; IC 95&#37;&#44; 12&#46;9&#8211;22&#46;9&#37;&#41; had eGFR &#60;30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> or did not have eGFR during the last year&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Selection of a limited sample of the total elegible population and restriction to a small spanish region were the main limitations of our study&#46; However&#44; others have shown similar results in other geographical areas with larger populations&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion&#44; the use of metformin and sulfonylureas were lower in patients with eGFR &#60;45<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> vs&#46; patients with eGFR &#8805;45<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> but 17&#46;5&#37; of patients &#8805;75 years-old treated with metformin or sulfonylureas had eGFR &#60;30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> or did not have eGFR during the last year&#46; It is necessary to monitor and help physicians to avoid inappropriate prescription specially in older people&#46;</p></span>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">eGFR 30&#8211;44<span class="elsevierStyleHsp" style=""></span>ml&#47;min&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 25300180
Original language: English
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