11
➤ In patients aged 65 years and older with diabetes who cannot achieve
glycemic targets with lifestyle modification, ES suggests avoiding the use
of restrictive diets and instead limiting consumption of simple sugars if
patients are at risk of malnutrition. (2|⊕
)
Technical Remarks:
▶ Patients' glycemic responses to changes in diet should be monitored closely.
▶ This recommendation applies to both older adults living in the community and
those in nursing homes.
Drug Therapy for Hyperglycemia
➤ In patients aged 65 years and older with diabetes, ES recommends
metformin as the initial oral medication chosen for glycemic management
in addition to lifestyle management. (1|⊕⊕⊕
)
Technical Remark: This recommendation should not be implemented in patients who
have significantly impaired kidney function (eGFR <30 mL/min/1.73 m
2
) or have a
gastrointestinal intolerance.
➤ In patients aged 65 years and older with diabetes who have not achieved
glycemic targets with metformin and lifestyle, ES recommends that other
oral or injectable agents and/or insulin should be added to metformin.
(1|⊕⊕⊕⊕)
Technical Remarks:
▶ To reduce the risk of hypoglycemia, avoid using sulfonylureas and glinides, and use
insulin sparingly.
▶ Glycemic treatment regimens should be kept as simple as possible.
Treating Complications of Diabetes
Hypertension
➤ In patients aged 65 to 85 years with diabetes, ES recommends a target
BP of 140/90 mmHg to decrease the risk of CVD outcomes, stroke, and
progressive CKD. (1|⊕⊕⊕
)
Technical Remarks:
▶ Patients in certain high-risk groups could be considered for lower BP targets
(130/80 mmHg ), such as those with previous stroke or progressing CKD (eGFR
<60 mL/min/1.73 m
2
and/or albuminuria). If lower BP targets are selected,
careful monitoring of such patients is needed to avoid orthostatic hypotension.
▶ Patients with high disease complexity (Group 3, Poor health, Table 3) could be
considered for higher BP targets (145–160/90 mmHg ).
▶ Choosing a BP target involves shared decision-making between the clinician and
patient, with full discussion of the benefits and risks of each target.
➤ In patients aged 65 years and older with diabetes and hypertension,
ES recommends that an angiotensin-converting enzyme inhibitor or an
angiotensin receptor blocker should be first-line therapy. (1|⊕⊕⊕
)
Technical Remark: If one class is not tolerated, the other should be substituted.
