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