Sciacqua Angela, Succurro Elena, Armentaro Giuseppe, Miceli Sofia, Pastori Daniele, Rengo Giuseppe, Sesti Giorgio
Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Campus Universitario di Germaneto, V.le Europa, 88100, Catanzaro, Italy.
Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy.
Heart Fail Rev. 2023 May;28(3):667-681. doi: 10.1007/s10741-021-10182-x. Epub 2021 Dec 2.
Heart failure (HF) and type 2 diabetes mellitus (T2DM) represent two important public health problems, and despite improvements in the management of both diseases, they are responsible for high rates of hospitalizations and mortality. T2DM accelerates physiological cardiac aging through hyperglycemia and hyperinsulinemia. Thus, HF and T2DM are chronic diseases widely represented in elderly people who often are affected by numerous comorbidities with important functional limitations making it difficult to apply the current guidelines. Several antidiabetic drugs should be used with caution in elderly individuals with T2DM. For instance, sulfonylureas should be avoided due to the risk of hypoglycemia associated with its use. Insulin should be used with caution because it is associated with higher risk of hypoglycemia, and may determine fluid retention which can lead to worsening of HF. Thiazolindinediones should be avoided due to the increased risk of fluid retention and HF. Biguanides may lead to a slightly increased risk of lactic acidosis in particular in elderly individuals with impaired renal function. Dipeptidyl peptidase 4 (DPP-4) inhibitors are safe having few side effects, minimal risk of hypoglycemia, and a neutral effect on cardiovascular (CV) outcome, even if it has been reported that saxagliptin treatment is associated with increased risk of hospitalizations for HF (hHF). Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have shown a CV protection without a significant reduction in hHF. On the other hand, sodium-glucose cotransporter 2 (SGLT2) inhibitors have shown a significant improvement in CV outcome, with a strong reduction of hHF and a positive impact on renal damage progression. However, it is necessary to consider the possible some side effects related to their use in elderly individuals including hypotension, bone fractures, and ketoacidosis.It is important to remark that elderly patients, in particular the very elderly, are not sufficiently represented in the trials; thus, the management and treatment of elderly diabetic patients with HF should be mainly based on the integration of scientific evidence with clinical judgment and patients' condition, with respect to the dignity and quality of life.
心力衰竭（HF）和2型糖尿病（T2DM）是两个重要的公共卫生问题，尽管这两种疾病的管理有所改善，但它们仍是住院率和死亡率居高不下的原因。T2DM通过高血糖和高胰岛素血症加速生理性心脏衰老。因此，HF和T2DM是老年人中广泛存在的慢性疾病，这些老年人常受多种合并症影响，存在严重的功能限制，使得当前指南难以应用。几种抗糖尿病药物在老年T2DM患者中应谨慎使用。例如，由于使用磺脲类药物有低血糖风险，应避免使用。胰岛素应谨慎使用，因为它与更高的低血糖风险相关，并且可能导致液体潴留，进而导致HF恶化。由于液体潴留和HF风险增加，噻唑烷二酮类药物应避免使用。双胍类药物可能会导致乳酸酸中毒风险略有增加，尤其是在肾功能受损的老年患者中。二肽基肽酶4（DPP-4）抑制剂是安全的，副作用少，低血糖风险最小，对心血管（CV）结局呈中性影响，即使有报道称沙格列汀治疗与HF住院（hHF）风险增加有关。胰高血糖素样肽-1受体激动剂（GLP-1 RAs）已显示出心血管保护作用，但hHF没有显著降低。另一方面，钠-葡萄糖协同转运蛋白2（SGLT2）抑制剂已显示出心血管结局有显著改善，hHF大幅降低，对肾脏损害进展有积极影响。然而，有必要考虑在老年患者中使用它们可能产生的一些副作用，包括低血压、骨折和酮症酸中毒。需要指出的是，老年患者，尤其是高龄患者，在试验中的代表性不足；因此，老年糖尿病合并HF患者的管理和治疗应主要基于科学证据与临床判断以及患者状况的结合，同时尊重患者的尊严和生活质量。
