Key takeaways:
- Trials assessing DPP-IV inhibitors, SGLT2 inhibitors and GLP-1s found no increased CV risk for older adults.
- Treatment guidance should include recommendations tailored to older populations.
PHILADELPHIA — The global populating is aging, and approximately 29% of people with diabetes worldwide are aged 65 years and older, representing 123 million people, according to a speaker at the Heart in Diabetes CME Conference.
Many adults in this age group have had diabetes for at least 10 years and are at risk for cardiovascular complications such as ischemic heart disease, acute myocardial infarction and cerebrovascular accident, according to Richard E. Pratley, MD, the Samuel E. Crockett Chair in Diabetes Research, medical director of AdventHealth Diabetes Institute and a Healio | Endocrine Today Co-editor, said here. However, most guidance for treating diabetes is focused on meeting glycemic targets. Pratley advocated for an approach that individualizes treatment and focuses on measures beyond glycemia for adults aged 65 years and older.
Personalized therapy that focuses on “improving health span” rather than life span is key for treating older adults with diabetes, according to a speaker at the Heart in Diabetes CME Conference.
“Our treatment guidelines need to continue to evolve to take into account the heterogeneity of older individuals as well as accumulating data on benefits and risks,” Pratley said during a presentation. “We need to personalize therapy in our older adults with diabetes, even more so than other populations.”
No increased CV risk for older adults
Widely used medications — DPP-IV inhibitors, SGLT2 inhibitors and GLP-1 receptor agonists — do not raise CV risk for older adults. However, health care professionals should be aware of other potential risks when prescribing medications, Pratley said.
Richard E. Pratley
FDA-issued guidance to assess CV risk for diabetes therapies has led to 28 CV outcome trials, to date, being conducted for eight classes of medication for type 2 diabetes. Pratley said these data have aided researchers in better understanding how diabetes medications affect CV outcomes for adults aged 65 years and older compared with younger adults.
A meta-analysis published in the Journal of Diabetes and Its Complications in 2024 examined CV risk with several classes of diabetes therapies by age group. In five trials that assessed DPP-IV inhibitors included in the meta-analysis, there was no difference in CV risk for adults aged 65 years and older and those 75 years and older compared with younger adults.
Some SGLT2 inhibitors may confer CV benefits for older adults. In the EMPA-REG Outcome trial, adults aged 65 years and older who received empagliflozin (Jardiance, Boehringer Ingelheim) had lower risk for CV outcomes and CV death compared with those who received placebo. Similarly, in the CANVAS trial, those aged 65 years and older who received canagliflozin (Invokana, Janssen) had decreased risk for CV outcomes compared with those in the placebo group.
CV benefits for older adults were also observed in some GLP-1 trials. In a post-hoc analysis of the LEADER trial published in Annals of Internal Medicine, adults aged 75 years and older who received liraglutide (Victoza/Saxenda, Novo Nordisk) had lower risk for CV outcomes and all-cause mortality than those who received placebo.
“We can use these drugs in patients who are older and who are at high risk for CVD safely.” Pratley said. “But we have to match benefits that we hope to achieve with these medications, which include reductions in CVD, heart failure, stroke and potentially diabetic kidney disease, with the risks of the therapy.”
Impact of lean mass loss
For older adults, a risk of treatment with a GLP-1 is a possible reduction in lean mass that could lead to falls or adverse bone health, according to Pratley. He said this is especially a concern for older adults who have sarcopenia when they start a GLP-1.
“We have to go into treatment with our eyes open,” Pratley said. “What we want to make sure is that in our efforts to improve CV outcomes, we’re not leading down a path where there’s accelerated loss of skeletal muscle and, consequently, function.”
Pratley concluded that while previously published trials showed older adults may confer additional benefits from SGLT2s and GLP-1s, more studies are needed so researchers can better understand which adults may confer the most benefits from therapies.
Pratley said the goal should be personalized therapy for older adults that focuses on “improving health span” rather than life span.
References:
Sources/Disclosures
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Pratley R. Diabetes Comorbidities. Presented at: Heart in Diabetes CME Conference; June 6-8, 2025; Philadelphia.
Disclosures:
Pratley reports speaking for Eli Lilly and Novo Nordisk; consulting for AbbVie, Altanine, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Corcept Therapeutics, Eli Lilly, Endogenex, F. Hoffman-La Roche, Gasherbrum Bio, Genprex, Getz Pharma, Hanmi Pharmaceutical, Intas Pharmaceuticals, Lexicon, Novo Nordisk, Pfizer, Regeneron, Scholar Rock and Sun Pharmaceuticals; and receiving research grants from Biomea Fusion, Carmot Therapeutics, Dompe, Eli Lilly, Endogenex, Fractyl, Novo Nordisk and Sanofi.
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