Overview
This Curbsiders podcast episode focuses on diabetes management in special populations, including older adults, pregnant women, and patients on steroid therapy. Expert endocrinologist Dr. Jeff Coburn joins the hosts to discuss clinical approaches, best practices, and medication choices tailored to these challenging cases.
Diabetes Management in Older Adults
- Prioritize avoidance of hypoglycemia due to increased risk of falls and cognitive impairment.
- Relax A1C and glucose targets (aim for A1C 7–8%, fasting 100–150 mg/dL, postprandial <180 mg/dL).
- De-escalate or discontinue high-risk hypoglycemic agents (e.g., sulfonylureas, insulin) if not needed.
- Use shared decision-making, considering mentation, medications, mobility, and patient goals (4 M framework).
- Simplify regimens, use once-daily insulin if needed, and leverage CGMs for monitoring.
- DPP-4 inhibitors and pioglitazone may be considered for select patients with low hypoglycemia risk.
Diabetes in Pregnancy and Gestational Diabetes
- A1C target in pregnancy is stricter (<6%) due to physiological changes affecting measurements.
- Glucose goals: fasting 70–95 mg/dL, 2-hr postprandial 100–120 mg/dL.
- Insulin is preferred during pregnancy; discontinue metformin, sulfonylureas, GLP-1 agonists, and SGLT2 inhibitors.
- Regular retinopathy screening before and during pregnancy is essential.
- Initiate insulin expeditiously, considering meal and fasting profiles; close follow-up and CGM are beneficial.
- Postpartum, emphasize risk of future type 2 diabetes and support weight management, avoiding contraindicated agents during breastfeeding.
Steroid-Induced Diabetes Management
- Steroids increase postprandial glucose most significantly.
- Adjust insulin by increasing prandial doses (start with 10–20% increments) to manage spikes.
- Consider replacing glargine with NPH insulin for better alignment with steroid action profile.
- For NPH, dose at 0.1–0.4 units/kg based on prednisone equivalent; split as 2/3 morning, 1/3 evening.
- Renal dysfunction increases risk of insulin stacking and hypoglycemia—monitor closely.
- GLP-1 agonists and SGLT2 inhibitors can be considered for longer-term use if appropriate.
Practical Tools and Additional Considerations
- Continuous glucose monitors are useful across all discussed populations for real-time data and safer titration.
- Involve families and caregivers in hypoglycemia prevention, especially for cognitively impaired patients.
- Use teach-back methods to confirm understanding of insulin regimens.
- Consider patient-specific factors such as comorbidities, medication access, and lifestyle in therapy decisions.
Decisions
- De-escalate high-risk diabetes medications in elderly with tight control/hypoglycemia.
- Switch to insulin-only therapy in pregnancy, discontinuing oral agents.
- Tailor steroid-induced diabetes regimens using NPH or prandial insulin adjustments.
Recommendations / Advice
- Use shared decision-making frameworks (4 Ms or 5 Ms) in older adults.
- Prioritize close monitoring and rapid adjustment of therapy in pregnancy and steroid use.
- Utilize CGMs for enhanced safety and individualized care.
- Refer to ADA guidelines for population-specific targets and medication guidance.