We used data from the GUIDANCE Study to determine the care of people with type 2 diabetes according to age and accompanying cardiovascular diseases and to assess indicators of overtreatment of glycaemia.
The GUIDANCE study was a retrospective, cross-sectional study from 2009–2010 based on the records of 7597 people in France, Belgium, Italy, the Netherlands, Sweden, UK, Ireland and Germany. We analysed the level of metabolic control achieved and blood glucose-lowering medication used in different age groups and in relation to accompanying diseases.
4.459 patients (59.1%) were 65 years or older. Their HbA1c levels were similar to those with <65 years. 44.7% of patients ≥65 years had an HbA1c ≤7% (53 mmol/mol) and were treated with insulin or sulfonylureas, and 27.1% of them had ischaemic heart disease or congestive heart failure. Significantly more patients with heart disease had HbA1c values ≤7% (53 mmol/mol) and were treated more often with insulin or sulfonylureas compared to patients of the same age without heart disease.
Most patients were treated according to guidelines valid at the time this large international patient sample was surveyed. Older and younger patients were at a similar level of metabolic control, and almost half of the patients with an age of ≥65 years and treated with insulin or sulfonylurea had HbA1c levels below the target range (≤7%) for younger patients. However, these patients have an increased risk of severe hypoglycaemic events with potentially dangerous complications, particularly in those with cardiovascular diseases.
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Stone MA, Charpentier G, Doggen K, Kuss O, Lindblad U, Kellner C et al (2013) Quality of care of people with type 2 diabetes in eight European countries: findings from the Guideline Adherence to Enhance Care (GUIDANCE) study. Diabetes Care 36:2628–2638
Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M et al (2012) Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 35(6):1364–1379
Vijan S, Sussman JB, Yudkin JS, Hayward RA (2014) Effect of patients’ risks and preferences on health gains with plasma glucose level lowering in type 2 diabetes mellitus. JAMA Intern Med 174(8):1227–1234
Seaquist ER, Anderson J, Childs B et al (2013) Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society. Diabetes Care 36(5):1384–1395
McCoy RG, Van Houten HK, Ziegenfuss JY, Shah ND, Wermers RA, Smith SA (2012) Increased mortality of patients with diabetes reporting severe hypoglycemia. Diabetes Care 35(9):1897–1901
Goto A, Arah OA, Goto M, Terauchi Y, Noda M (2013) Severe hypoglycaemia and cardiovascular disease: systematic review and meta-analysis with bias analysis. BMJ 347:f4533
Nicolucci A, Pintaudi B, Rossi MC et al (2015) The social burden of hypoglycemia in the elderly. Acta Diabetol 52(4):677–685
Tsujimoto T, Yamamoto-Honda R, Kajio H, Kishimoto M, Noto H, Hachiya R et al (2015) Prediction of 90-day mortality in patients without diabetes by severe hypoglycemia: blood glucose level as a novel marker of severity of underlying disease. Acta Diabetol 52:307–314
Muller UA, Femerling M, Reinauer KM, Risse A, Voss M, Jorgens V et al (1999) Intensified treatment and education of type 1 diabetes as clinical routine. A nationwide quality-circle experience in Germany ASD (the Working Group on Structured Diabetes Therapy of the German Diabetes Association) (Abstract). Diabetes Care 22(Suppl 2):B29–B34
Action to Control Cardiovascular Risk in Diabetes Study, Group (2008) Effects of intensive glucose lowering in type 2 diabetes. NEJM 358:2545–2559
Lipska KJ, Yao X, Herrin J, McCoy RG, Ross JS, Steinman MA et al (2016) Trends in drug utilization, glycemic control, and rates of severe hypoglycemia, 2006–2013. Diabetes Care 22:dc160985 (Epub ahead of print)
Lipska KJ, Ross JS, Miao Y, Shah ND, Lee SJ, Steinman MA (2015) Potential overtreatment of diabetes mellitus in older adults with tight glycemic control. JAMA Intern Med 175:356–362
Feil DG, Rajan M, Soroka O, Tseng CL, Miller DR, Pogach LM (2011) Risk of hypoglycemia in older veterans with dementia and cognitive impairment: implications for practice and policy. J Am Geriatr Soc 59:2263–2272
Liebl A, Mata M, Eschwege E, Advisory Board ODE (2002) Evaluation of risk factors for development of complications in Type II diabetes in Europe. Diabetologia 45:S23–28
Pani LN, Korenda L, Meigs JB, Driver C, Chamany S, Fox CS et al (2008) Effect of aging on A1C levels in individuals without diabetes: evidence from the Framing-ham Offspring Study and the National Health and Nutrition Examination Survey. 2001–2004. Diabetes Care 31:1991–1996
Carrera T, Bonamusa L, Almirall L, Navarro JM (1998) Should age and sex be taken into account in the determination of HbA1c reference range? Diabetes Care 21:2193
Lipska KJ, Krumholz H, Soones T, Lee SJ (2016) Polypharmacy in the aging patient: a review of glycemic control in older adults with type 2 diabetes. JAMA 315:1034–1045
Deaton A (2013) The great escape, health wealth and origins of inequality. Princeton University Press, Princeton
KK acknowledges the support from the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care—East Midlands (NIHR CLAHRC—EM), the Leicester Clinical Trials Unit and the NIHR Leicester-Loughborough Diet, Lifestyle and Physical Activity Biomedical Research Unit. KK has acted as a consultant and speaker for Novartis, Novo Nordisk, Sanofi-Aventis, Lilly and Merck Sharp & Dohme. He has received grants in support of investigator and investigator initiated trials from Novartis, Novo Nordisk, Sanofi-Aventis, Lilly, Pfizer, Boehringer Ingelheim and Merck Sharp & Dohme. KK has received funds for research, honoraria for speaking at meetings and has served on advisory boards for Lilly, Sanofi-Aventis, Merck Sharp & Dohme and Novo Nordisk.
NM researched data and wrote the manuscript, KK reviewed/edited the manuscript and contributed to the discussion, OK researched data and reviewed/edited the manuscript, UL reviewed/edited the manuscript and contributed to the discussion, and JN reviewed/edited the manuscript and contributed to the discussion. GR reviewed/edited the manuscript and contributed to the discussion, MT reviewed/edited the manuscript and contributed to the discussion, MP reviewed/edited the manuscript and contributed to the discussion, JR contributed to the discussion, GC reviewed/edited the manuscript, VJ reviewed/edited the manuscript and contributed to the discussion, and UAM had the research idea, contributed to the discussion and reviewed/edited the manuscript.
The GUIDANCE study was funded by the European Association for the Study of Diabetes from a grant from Merck & Co. (Whitehouse Station, NJ). Merck scientists participated in the initial conceptualisation and protocol development but were not involved in the conduct of the study or in the analysis and interpretation of the data collected. The present analysis was funded by the Diabetes Centre Thuringia, Germany, a non-profit-making organisation for diabetes education and research.
Conflict of interest
No other potential conflicts of interest relevant to this article were reported.
The responsible Ethics Committee in each country had given approval.
Human and animal rights
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5).
Informed consent was obtained from all patients for being included in the study.
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Müller, N., Khunti, K., Kuss, O. et al. Is there evidence of potential overtreatment of glycaemia in elderly people with type 2 diabetes? Data from the GUIDANCE study. Acta Diabetol 54, 209–214 (2017). https://doi.org/10.1007/s00592-016-0939-9
- Type 2 diabetes