Antidiabetic oral treatment in older people: does frailty matter?

Life expectancy has significantly increased over the past 30 years, with a greater prevalence of diverse disease states, especially type 2 diabetes mellitus. As older persons are a very heterogeneous group with an increased prevalence of comorbidities and a relative inability to tolerate the adverse effects of oral antidiabetic agents, the treatment of type 2 diabetes is particularly demanding. The principles of its management are similar to those in younger patients, but with special considerations linked to comorbidities and clinical status. The available oral antidiabetic drugs include insulin secretagogues (meglitinides and sulfonylureas), biguanides (metformin), alpha-glucosidase inhibitors, thiazolidinediones and newly introduced inhibitors of glucagon-like peptide 1 degrading enzyme dipeptidyl peptidase 4 (DPP-4). In addition, clinical aspects complicate diabetes care in the elderly, including cognitive disorders, physical disability and geriatric syndromes, such as frailty. The European Diabetes Working Party for Older Persons has increased glycaemic recommendations for target haemoglobin A(1c) from <7% to <or=8% in the presence of frailty. This working party updated their guidelines in 2008 and their aim is to ensure that older Europeans with type 2 diabetes have high-quality diabetes care throughout their lives. The working party has created guidelines for the use of many drugs, and we will discuss some of these guidelines on the use of oral antidiabetic agents and their importance in the presence of frailty. Furthermore, as type 2 diabetes progresses in older persons, polypharmacy intensification is usually required to reach adequate glycaemic control, with the risk of adverse effects. In particular, clinical evidence shows that the use of sulfonylureas is associated with a greater risk of hypoglycaemica, whereas metformin and alpha-glucosidase inhibitors are associated with an increased risk of adverse gastrointestinal effects. The adverse effects of the recently introduced DPP-4 inhibitors are nasopharyngitis and/or upper respiratory tract infections. The literature suggests that oral antidiabetic agents are suitable for older persons; however, underappreciated risk factors, such as cognitive decline in frail individuals, have an important impact on oral antidiabetic treatment options.