Progress towards a personalized management of antidiabetic medications in the elderly with type 2 diabetes.

Introduction: Older adults with type 2 diabetes mellitus (T2DM) are increasingly numerous worldwide and present particularly difficult therapeutic challenges, especially concerning the proper selection of antidiabetic medications that offer the best efficacy/safety ratio in this age group.

Areas covered: This narrative review summarizes progress toward personalized management involving a three-step process. First, patients should be categorized according to their frailty status. Second, glycemic targets should be properly individualized considering a higher risk of severe hypoglycemia in older patients. Third, the selection of the best antidiabetic medication(s) in order to avoid hypoglycemia but also to offer cardiorenal protection. In this respect, sulfonylureas and insulin therapy are currently less recommended and newer antidiabetic medications are preferred, usually combined with metformin: DPP-4 inhibitors (gliptins) for their better safety profile versus sulfonylureas, GLP-1 analogues or SGLT2 inhibitors (gliflozins) if cardiorenal protection is required. Reducing excessive body weight appears less critical in older patients and sarcopenia should be avoided.

Expert opinion: The two most recognized challenges are undertreating healthy older patients while overtreating frailty/ill people. The increasing armamentarium to treat T2DM offers new opportunities to personalize the use of antidiabetic medications according to the clinical profile and need of every older patient with T2DM.