Management of Hypertension and Diabetes in Aging People 2014

Hypertension and Diabetes
in the Aging Patient
Nemencio A. Nicodemus Jr., MD
Associate Professor
UP College of Medicine
Endocrinology, Diabetes & Metabolism

Intended Learning Outcomes
• To discuss the recommendations in the
management of elevated blood pressure in
the aging population
• To discuss the recommendations in the
management of diabetes in older patients

Who are the older population?
The UN agreed cutoff is 60+ years

Age-related chronic diseases rise
exponentially with age
Age
INCIDENCE

“Honest doc--if I had known I was gonna to live this
long, I’d have taken better care of myself.”

What is the normal blood pressure?
Less than

Classification of Blood Pressure
For Adults
BP Classification SBP mmHg DBP mmHg
Normal <120 and <80
Prehypertension 120–139 or 80–89
Stage 1 Hypertension 140–159 or 90–99
Stage 2 Hypertension >160 or >100
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure (JNC 7), Dec 2003

Target Organ Damage With
Hypertension
• Heart
– Left ventricular hypertrophy
– Angina or prior myocardial infarction
– Prior coronary revascularization
– Heart failure

Hypertension
• Brain
– Stroke or transient ischemic attack

Hypertension
Chronic kidney disease
Peripheral arterial disease
Retinopathy

Systolic or Diastolic: Which is more
important?
• In persons older than 50 years, systolic BP >140
mmHg is a much more important cardiovascular
disease (CVD) risk factor than diastolic BP

When does the risk of CVD start to
rise?
• The risk of CVD beginning at 115/75
mmHg doubles with each increment of
20/10 mmHg
• Individuals who are normotensive at age
55 have a 90% lifetime risk for developing
hypertension

Motivation is the key to controlling
blood pressure!
• The most effective therapy prescribed by
the most careful clinician will control
hypertension only if patients are
motivated.
• Motivation improves when patients have
positive experiences with, and trust in, the
clinician.
• Empathy builds trust and is a potent
motivator

IN THE GENERAL POPULATION AGED
60 YEARS OR OLDER

Initial Considerations in the Management of
Elevated Blood Pressure
James PA, et al for the JNC 8. JAMA. doi:10.1001/jama.2013.284427. Published online December 18, 2013

Lifestyle modifications to manage
hypertension
Modification Recommendation
Weight reduction Maintain normal body weight
Adopt DASH eating plan Consume a diet rich in fruits,
vegetables, and low-fat dairy
products with a reduced content
of saturated and total fat
Dietary sodium
reduction
Reduce dietary sodium intake to
no more than 100 mmol per day
(2.4 g sodium or 6 g sodium
chloride)

Lifestyle modifications to manage
hypertension
Modification Recommendation
Physical activity Engage in regular aerobic physical
activity such as brisk walking (at
least 30 min per day, most days of
the week).
Moderation of alcohol
consumption
Limit consumption to no more than
2 drinks per day in most men and to
no more than 1 drink per day in
women and lighter weight persons
(1 oz or 30 mL ethanol; e.g., 24 oz
beer, 10 oz wine, or 3 oz 80-proof
whiskey)

When to initiate pharmacologic
treatment?
Systolic BP ≥150 mmHg or
diastolic BP ≥90 mmHg

What is the goal blood pressure?
SBP < 150mmHg and
DBP < 90mmHg

What target a BP <150/90 mm Hg?
• Treating high BP to a goal of lower than
150/90 mm Hg reduces stroke, heart
failure, and coronary heart disease
• Setting a goal SBP of lower than 140 mm
Hg in this age group provides no additional
benefit

Setting Target BP Based On Age
And Co-morbidities

Is there a need to adjust treatment if a
lower blood pressure is achieved?
If pharmacologic treatment is well tolerated
and without adverse effects on health or
quality of life, treatment does not need to be
adjusted

Drug Treatment Titration Strategies
1
• Maximize first medication before adding
second or
2
• Add second medication before reaching
maximum dose of first medication or
3
• Start with 2 medication classes
separately or as fixed-dose combination

Which BP-lowering Drug To Start?

Goal BP and Initial Drug Therapy
for Adults With Hypertension

Recommendations On Drug Therapy
• If goal BP is not reached
within a month of treatment.
. .
• If goal BP cannot be
reached with 2 drugs. . .
• If goal BP cannot be
reached using only the
drugs in recommendation,
because of a
contraindication or the need
to use more than 3 drugs to
reach goal BP. . .
• increase the dose of the
initial drug or add a second
drug from one of the
classes in recommendation
• add and titrate a third drug
• antihypertensive drugs from
other classes can be used

Dosing For Anti-Hypertensive Drugs

Aging-associated Physiological Changes that Affect
Pharmacodynamics

Aging-associated Physiological Changes that Affect
Pharmacokinetics

What is Patient-Centered Approach?
“...providing care that is respectful of and
responsive to individual patient preferences,
needs, and values – ensuring that patient
values guide all clinical decisions.”
Inzucchi SE, et al. ADA-EASD Position Statement. Diabetes Care, Diabetologia. 19 April 2012 [Epub ahead of print]

UKPDS: Each 1%
reduction in HbA1c was
associated with 14%
reductions in risk for MI
UKPDS 35. BMJ 2000; 321: 405-12

Impact of Intensive Therapy For
Diabetes
Study Microvasc CVD Mortality
UKPDS      
DCCT/EDICT      

ACCORD   
ADVANCE   
VADT   
initial Long-term ff-up
Kendall DM, Bergenstal RM. © International Diabetes Center 2009
UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998;352:854.
Holman RR et al. N Engl J Med. 2008;359:1577. DCCT Research Group. N Engl J Med 1993;329;977.
Nathan DM et al. N Engl J Med. 2005;353:2643. Gerstein HC et al. N Engl J Med. 2008;358:2545.
Patel A et al. N Engl J Med 2008;358:2560. Duckworth W et al. N Engl J Med 2009;360:129. (erratum:
Moritz T. N Engl J Med 2009;361:1024)

Large Clinical Type 2 Diabetes Trials
UKPDS
(n=3867)
ADVANCE
(n=11,140)
ACCORD
(n=10,251)
VADT
(n=1,791)
Duration of
diabetes
0 8 10 11.5
Mean age (yr) 53 66 62 60
History of CVD - 32% 34% 40%
Achieved A1c
Conventional
Intensive
7.9%
6.2%
7.3%
6.5%
7.5%
6.4%
8.4%
6.9%
Holman RR et al. N Engl J Med. 2008;359:1577. DCCT Research Group. N Engl J Med 1993;329;977.
Nathan DM et al. N Engl J Med. 2005;353:2643. Gerstein HC et al. N Engl J Med. 2008;358:2545.
Patel A et al. N Engl J Med 2008;358:2560. Duckworth W et al. N Engl J Med 2009;360:129. (erratum:
Moritz T. N Engl J Med 2009;361:1024)

Factors To Consider In Individualizing
Approach to Management
Patient attitude
and expected
treatment efforts
Risk of
hypoglycemia and
other adverse
events
Diabetes duration
Patient’s life
expectancy
Important co-morbid
conditions
Presence of
vascular
complications
Available
resources, support
systems
Inzucchi SE, et al. ADA-EASD Position Statement. Diabetes Care, Diabetologia. 19 April 2012

Approach to Management of Hyperglycemia
More stringent Less stringent
Risks with
hypoglycemia or
adverse events
Low High
Disease duration New Long-standing
Life expectancy Long Short
Important co-morbidities
Absent Few /mild Severe
Established
vascular
complications
Absent Few/mild Severe
Modified from Diabetes Care, Diabetologia. 19 April 2012

Individualization of Glycemic Targets
HbA1c
7.5–8.0%
• Patients with history of
severe hypoglycemia, limited
life expectancy, advanced
complications, extensive
comorbid conditions
HbA1c
<7.0%
• In most
patients
HbA1c
6.0– 6.5%
• Patients with short
disease duration, long
life expectancy, no
significant CVD
Diabetes Care, Diabetologia. 19 April 2012 [Epub ahead of print]

Individualization is Key to Glycemic Targets
Tighter targets
(6.0 - 6.5%) Looser targets
(7.5 - 8.0%+)
•Younger
•Healthier
•Older
•Comorbidities
•Hypoglycemia prone, etc.
Avoidance of hypoglycemia
Inzucchi SE, et al. ADA-EASD Position Statement. Diabetes Care, Diabetologia. 19 April 2012

Rules For Glycemic Target Personalization
Age
Body
compo
sition
Complications
Duration

Anti-hyperglycemic Therapeutic Options
Lifestyle
Oral
agents &
non-insulin
injectables
Insulin

Implementation Strategies For
Anti-hyperglycemic Therapies
Initial therapy
Dual
combination
therapy
Triple
combination
therapy
Transitions to
& titrations of
insulin

Initial drug
monotherapy
Efficacy (! HbA1c)
Hypoglycemia
Weight
Side effects
Costs
Healthy eating, weight control, increased physical activity
Metformin
high
low risk
neutral/loss
GI / lactic acidosis
low
If needed to reach individualized HbA1c target after ~3 months, proceed to 2-drug combination
(order not meant to denote any specific preference):
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Efficacy (! HbA1c)
Hypoglycemia
Weight
Major side effect(s)
Costs
Thiazolidine-dione
high
low risk
gain
edema, HF, fx’s‡
high
DPP-4
Inhibitor
intermediate
low risk
neutral
rare‡
high
Insulin (usually
basal)
highest
high risk
gain
hypoglycemia‡
variable
Two drug
combinations*
Sulfonylurea†
+
Thiazolidine-dione
+
DPP-4
Inhibitor
+
GLP-1 receptor
agonist
GLP-1 receptor
agonist
+
Insulin (usually
basal)
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
TZD
DPP-4-i
GLP-1-RA
Insulin§
SU†
DPP-4-i
GLP-1-RA
Insulin§
SU† SU†
TZD TZD
TZD
DPP-4-i
Insulin§ Insulin§
If combination therapy that includes basal insulin has failed to achieve HbA1c target after 3-6 months,
proceed to a more complex insulin strategy, usually in combination with 1-2 non-insulin agents:
Insulin#
(multiple daily doses)
Three drug
combinations
More complex
insulin strategies
or
or
or
or
or
or
or
or
or
or
or
or GLP-1-RA
high
low risk
loss
GI‡
high
Sulfonylurea†
high
moderate risk
gain
hypoglycemia‡
low
Diabetes Care, Diabetologia. 19 April 2012 [Epub ahead of print]

Initial drug
monotherapy
Efficacy (! HbA1c)
Hypoglycemia
Weight
Side effects
Costs
Metformin
high
low risk
neutral/loss
low
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Efficacy (! HbA1c)
Hypoglycemia
Weight
Costs
Thiazolidine-dione
high
low risk
gain
high
DPP-4
Inhibitor
intermediate
low risk
neutral
rare‡
high
Insulin (usually
basal)
highest
high risk
gain
hypoglycemia‡
variable
Two drug
combinations*
Sulfonylurea†
+
Thiazolidine-dione
+
DPP-4
Inhibitor
+
GLP-1 receptor
agonist
GLP-1 receptor
agonist
+
Insulin (usually
basal)
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
TZD
DPP-4-i
GLP-1-RA
Insulin§
SU†
DPP-4-i
GLP-1-RA
Insulin§
SU† SU†
TZD TZD
TZD
DPP-4-i
Insulin§ Insulin§
If combination therapy that includes basal insulin has failed to achieve HbA1c target after 3-6 months,
proceed to a more complex insulin strategy, usually in combination with 1-2 non-insulin agents:
Insulin#
Three drug
combinations
More complex
insulin strategies
or
or
or
or
or
or
or
or
or
or
or
or GLP-1-RA
high
low risk
loss
GI‡
high
Sulfonylurea†
high
moderate risk
gain
hypoglycemia‡
low
Diabetes Care, Diabetologia.
19 April 2012 [Epub ahead of print]

Age as a consideration For DM Management
•Older adults
- Reduced life expectancy
- Higher CVD burden
- Reduced GFR
- At risk for adverse events from polypharmacy
- More likely to be compromised from hypoglycemia
 Less ambitious targets
 HbA1c <7.5–8.0% if tighter
targets not easily achieved
 Focus on drug safety

Initial drug
monotherapy
Efficacy (! HbA1c)
Hypoglycemia
Weight
Side effects
Costs
Metformin
high
low risk
neutral/loss
low
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Efficacy (! HbA1c)
Hypoglycemia
Weight
Costs
Thiazolidine-dione
high
low risk
gain
high
DPP-4
Inhibitor
intermediate
low risk
neutral
rare‡
high
Insulin (usually
basal)
highest
high risk
gain
hypoglycemia‡
variable
Two drug
combinations*
Sulfonylurea†
+
Thiazolidine-dione
+
DPP-4
Inhibitor
+
GLP-1 receptor
agonist
GLP-1 receptor
agonist
+
Insulin (usually
basal)
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
TZD
DPP-4-i
GLP-1-RA
Insulin§
SU†
DPP-4-i
GLP-1-RA
Insulin§
SU† SU†
TZD TZD
TZD
DPP-4-i
Insulin§ Insulin§
Insulin#
Three drug
combinations
More complex
insulin strategies
or
or
or
or
or
or
or
or
or
or
or
or GLP-1-RA
high
low risk
loss
GI‡
high
Sulfonylurea†
high
moderate risk
gain
hypoglycemia‡
low
Adapted Recommendations: When Goal is to Avoid Hypoglycemia

Summary
• In the old population, BP targets and
management options are slightly different
from the younger population
• Diabetes management in the older
patients must consider not just efficacy,
but more importantly safety

Management of Hypertension and Diabetes in Aging People 2014

Management of Hypertension and Diabetes in Aging People 2014

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