Management of Type 2 Diabetes and Cardiovascular Disease in Older Adults

Introduction to Medication Recommendations

• The European Society of Cardiology recommends SGLT2 inhibitors (empagliflozin, canagliflozin, or dapagliflozin) and GLP-1 receptor agonists (liraglutide, semaglutide, or dulaglutide) as the cornerstone of medication regimen for patients with type 2 diabetes and cardiovascular disease, in addition to current anticoagulation and lipid management therapy 1, 2, 3

Diabetes Management

• The American Diabetes Association recommends metformin for patients with type 2 diabetes if eGFR >30 mL/min/1.73m², as it may provide additional benefits in combination with newer agents 4, 3, 5
• The European Association for the Study of Diabetes recommends avoiding thiazolidinediones due to risk of heart failure and edema 1, 3
• The American Heart Association recommends avoiding saxagliptin due to increased risk of heart failure 1, 2, 3
• The American Geriatrics Society recommends avoiding sulfonylureas due to high hypoglycemia risk in older adults 4, 6, 7

Cardiovascular Management

• The American College of Cardiology recommends continuing Eliquis (apixaban) for atrial fibrillation to prevent stroke 8
• The European Society of Cardiology recommends continuing Repatha (evolocumab) as PCSK9 inhibitor for lipid management 1, 3
• The American Heart Association recommends adding a RAAS blocker (ACE inhibitor or ARB) for hypertension management in diabetes, especially with intermittent high blood pressure 1, 3

Neuropathy Management

• The American Academy of Neurology recommends pregabalin or duloxetine for diabetic peripheral neuropathy to improve quality of life 9

Medication Simplification Strategy

• The American Geriatrics Society recommends aiming for once-daily dosing when possible and prioritizing medications with dual benefits (e.g., SGLT2 inhibitors for both diabetes and heart failure) 6, 7, 1, 3

Special Considerations

• The American Diabetes Association recommends setting individualized A1C target of 7.5-8.0% given age and multiple comorbidities 6, 7
• The European Society of Cardiology recommends avoiding medications with high hypoglycemia risk (sulfonylureas, certain insulins) 4, 6
• The American Heart Association recommends considering adding low-dose aspirin with proton pump inhibitor if not contraindicated 1, 3

Implementation Plan

• The European Society of Cardiology recommends starting with empagliflozin (SGLT2 inhibitor) at low dose and titrating as tolerated, and adding liraglutide (GLP-1 receptor agonist) if A1C remains above target 1, 3

Monitoring Recommendations

• The American Society of Nephrology recommends monitoring renal function before and after initiating SGLT2 inhibitor 1, 3
• The American Heart Association recommends checking blood pressure regularly, especially given history of variable readings 3
• The American Diabetes Association recommends monitoring for hypoglycemia, especially given age and multiple comorbidities 4, 6
• The American Geriatrics Society recommends assessing cognitive function periodically 6