Table 4

Advantages, disadvantages, and caveats in using glucose-lowering agents in LTC population

AdvantagesDisadvantagesCaveats in LTC population
Biguanides• Low hypoglycemia risk• Many contraindications in population with high comorbidity burden• Can be used until estimated glomerular filtration rate is <30 mL/min/1.73 m2
Metformin• Low cost
• Known side effects
• Established safety record
• May cause weight loss or gastrointestinal upset in frail patients• Extended release formulation has lower complexity and fewer gastrointestinal side effects
• Assess for vitamin B12 deficiency
Sulfonylureas• Low cost• High risk of hypoglycemia
• Glyburide has the highest risk of hypoglycemia and should be avoided
• Avoid if inconsistent eating pattern
• Careful glucose monitoring during acute illness or weight loss
• Consider discontinuing if already on substantial insulin dose (e.g., >40 units/day)
Meglitinides• Short duration of action• Can be held if patient refuses to eat• Some risk of hypoglycemia
• Increased regimen complexity due to multiple daily mealtime doses
TZDs• Low hypoglycemia risk
• Low cost
• Can be used in renal impairment
• Many contraindications in population with high comorbidity burden• Less concern for bladder cancer if shorter life expectancy
DPP-4 inhibitors• Low hypoglycemia risk
• Once-daily oral medication
• High cost
• Lower efficacy
• Can be combined with basal insulin for a low complexity regimen
SGLT2 inhibitors• Low hypoglycemia risk• High cost
• Limited evidence in LTC population
• Watch for increased urinary frequency, incontinence, lower blood pressure, genital infections, and dehydration
GLP-1 agonists• Low hypoglycemia risk
• Once-daily and once-weekly formulation
• High cost
• Injection
• Monitor for anorexia and weight loss
Insulin• No ceiling effect
• Many different types can be used to target hyperglycemia at different times of the day
• High risk of hypoglycemia
• Matching carbohydrate content with prandial insulin if variable appetite
• Basal insulin combined with oral agents may lower postprandial glucose while reducing hypoglycemia risk and regimen complexity
• Continue basal–bolus regimen in patients with type 1 or insulin-deficient type 2 diabetes
  • DPP-4, dipeptidyl peptidase 4; GLP-1, glucagon-like peptide 1; SGLT2, sodium–glucose cotransporter 2; TZDs, thiazolidinediones.