gms | German Medical Science

Background: Nearly half of 65- to 79-year-olds with type 2 diabetes in Germany have cardiovascular diseases (CVD) and more than 80% have hypertension [1]. For older adults with diabetes with concomitant CVD or at high risk of CVD, clinical guidelines recommend metformin and glucose-lowering agents with proven CVD benefits, such as glucagon-like peptide-1 (GLP-1) receptor agonists or sodium-glucose co-transporter-2 (SGLT2) inhibitors, as first-line therapy for glycemic management [2]. Further, statin therapy is recommended either for primary or secondary CVD prevention and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are the first-line agents for hypertension treatment [3]. Guideline-based pharmacotherapy of people with diabetes is critical for achieving individualized hemoglobin A1c (HbAc1) targets and preventing diabetes-related complications and cardiovascular comorbidities. We thus examined pharmacological therapy for older adults with diabetes considering potential sex differences [4].

Methods: The Study on Health of Older People in Germany (Gesundheit 65+) was conducted among people aged 65 years and older who were sampled nationwide and surveyed between 06/2021-04/2022 (baseline, N=3694) [5]. At follow-up one year later, a short non-invasive examination was offered in addition to the health questionnaire/interview (follow-up, N=1493). At both time points, we collected data on chronic conditions including diabetes and CVD in the last 12 months. All medicines used in the 7 days before the examination at follow-up were documented with an anatomical therapeutic chemical (ATC) code. Individuals with diabetes were defined as those who reported diabetes either at baseline or follow-up or those under antidiabetic medications (ATC-code A10) (N=292). CVD was defined by self-reported coronary heart disease and stroke at baseline/follow-up, and hypertension was defined based on measured blood pressure ≥140/90 mmHg or intake of medication with antihypertensive main effects among participants who reported a hypertension diagnosis at baseline/follow-up.

Results: Of people with diabetes (mean age 76.4 years, women 47.1%, CVD 42.6%, hypertension 81.5%), 4.0% (men 5.2% vs. women 2.5%) used only insulin, 56.7% (62.4% vs. 50.3%) only oral/injectable agents other than insulin, 12.9% (17.1% vs. 8.3%) a combination of both, and 26.4% (15.3% vs. 38.9%) no antidiabetic drugs (p=.01). Use of any metformin (total 54.0%, men 63.5% vs. women 43.3%) and insulin (16.9%, 22.3% vs. 10.8%) was higher in men than in women. No significant sex differences were found for the use of any GLP-1 agonists/SGLT2 inhibitors (total 21.4%, men 26.6% vs. women 15.6%), statins (65.9%, 67.3% vs. 63.8%) or ACE inhibitors/ARBs (76.6%, 79.4% vs. 73.3%). Combined use of metformin and GLP-1-agonists/SGLT2-inhibitors was 11.5% (men 16.1% vs. women 6.4%, p=.03) overall or 17.4% (20.0% vs. 13.7%, p=.54) among people with CVD. 4.0% used potentially inappropriate glucose-lowering agents for older adults, such as Glimepirid.

Conclusions: Without considering parameters of clinical complexity (e.g. diabetes duration, HbA1c values and life expectancy) and given the relatively low combined use of metformin and GLP-1-agonists/SGLT2-inhibitors as well as the use of potentially inappropriate glucose-lowering agents, drug therapy for older adults with diabetes could be further improved in line with the recommendations of clinical guidelines. Sex differences in drug therapy need to be further analyzed.

The authors declare that they have no competing interests.

The authors declare that an ethics committee vote is not required.