Sheffield Kidney Institute, Sheffield Teaching Hospitals, Herries Road, Sheffield S5 7AU, UK.
Translational Health Sciences, Bristol Medical School, Bristol, BS8 1QU.
Diabetes Res Clin Pract. 2024 May;211:111662. doi: 10.1016/j.diabres.2024.111662. Epub 2024 Apr 9.
Metabolic targets are controversial in older people with type 2 diabetes due to functional heterogeneity and morbidity burden. Tight blood pressure and metabolic control appears beneficial in fit individuals who are newly diagnosed with type 2 diabetes and have fewer comorbidities. The benefits of low blood pressure and tight metabolic control is attenuated with the development of comorbidities, especially frailty. Guidelines consider frail older people as one category and recommend relaxed targets. However, sarcopenic obese frail individuals may benefit from tight targets and intensification of therapy due to their unfavourable metabolic profile, accelerated diabetes trajectory and high cardiovascular risk. In addition, the early use of sodium glucose transporter-2 inhibitors and glucagon like peptide-1 receptor agonists may be beneficial in this frailty phenotype due to their cardio-renal protection, which is independent of glycaemic control, provided they are able to engage in resistance exercise training to avoid loss of muscle mass. In the anorexic malnourished frail individual, early use of insulin, due to its weight gain and anabolic properties, is appropriate. In this phenotype, targets should be relaxed with deintensification of therapy due to significant weight loss, decelerated diabetes trajectory and increased risk of medication side effects.
由于功能异质性和发病负担，代谢目标在 2 型糖尿病老年患者中存在争议。在新诊断为 2 型糖尿病且合并症较少的健康人群中，严格的血压和代谢控制似乎是有益的。随着合并症的发展，特别是虚弱的发生，低血压和严格代谢控制的益处会减弱。指南将虚弱的老年人视为一类人群，并建议放宽目标。然而，由于代谢异常、糖尿病进展加速和心血管风险高，肌肉减少性肥胖虚弱患者可能受益于严格的目标和治疗强化。此外，由于钠-葡萄糖共转运蛋白 2 抑制剂和胰高血糖素样肽-1 受体激动剂具有心脏肾脏保护作用（独立于血糖控制），在这种虚弱表型中早期使用可能有益，只要他们能够进行抗阻运动训练以避免肌肉量的减少。在消瘦营养不良的虚弱个体中，由于其增加体重和合成代谢特性，早期使用胰岛素是合适的。在这种表型中，由于体重显著减轻、糖尿病进展减缓以及药物副作用风险增加，应放宽目标并减少治疗强度。
