Table 2: Non-Insulin pharmacotherapy options for Type 2 Diabetes Mellitus in the elderly. Listed medications are limited to those commercially available in the U.S. at time of manuscript submission.

 

Type of Medication (Generic names)

Primary Mechanism of Action

Benefits in the Elderly

Concerns in the Elderly

Biguanide

(metformin)

Reduce Hepatic Glucose Production

         High Efficacy

         Low cost

         Modest Weight Loss

         Low Risk of Hypoglycemia

Caution with Renal Disease, Heart Failure, Liver Disease Due to Risk of Lactic Acidosis

Sulfonylureas

(glimepiride, glyburide, glipizide)

Insulin Secretagogue

         High efficacy

         Low cost

         Hypoglycemic risk with Advancing Age

         Caution in Liver Disease

Meglitinides

(nateglinide, repaglinide)

Insulin Secretagogue

         Lower Risk of Hypoglycemia Compared to Sulfonylureas

         Hypoglycemic risk with advancing age

         Frequent administration

         Caution in Liver Disease

Glucagon-like peptide-1 Agonists

(liraglutide, exenatide, exenatide XR, albiglutide, dulaglutide)

Insulin Secretagogue

Increase Incretin Effect

         Low risk for Hypoglycemia

         Weight loss

         Gastroparesis

         Pancreatitis

         Injectable therapy

Dipeptidyl-peptidase IV Inhibitors

(sitagliptin, linagliptin, alogliptin, saxagliptin)

Insulin Secretagogue

Increase Incretin Effect

         Low Risk for Hypoglycemia; Weight neutral

         Pancreatitis

         Modest Reduction in HgBA1c

         Expensive

Thiazolidinediones

(pioglitazone, rosiglitazone)

Increase Insulin Sensitivity

         Low risk of hypoglycemia

         Lower BMD and increase fracture risk [249]

         Caution in Renal and Liver disease, Heart Failure

         Weight gain and Fluid retention

Alpha-glucosidase inhibitors

(acarbose, miglitol)

Reduce Carbohydrate Absorption

         Possible reduction in cardiovascular events [237].

         Caution in Renal, Liver Disease and Malabsorptive Syndromes

         Gastrointestinal side effects common

Sodium-glucose co-transporter-2 Inhibitors

(empagliflozin, canagliflozin, dapagliflozin)

Increase Urinary Glucose Excretion

         Possible Cardiovascular Benefit [238].

         Reduction in blood pressure

         Increased risk of UTI and yeast infection

         Dehydration common side effect

         Increased urinary frequency

         Limited efficacy with chronic kidney disease

         Expensive

Amylin replacement

(pramlintide)

Amylin Replacement

         Weight Loss

         Gastro paresis

         Multiple daily injections

         Modest HgBA1c reduction