Anti diabetic agents

Poorly controlled diabetes can result in various complications that can predispose the patient to fall incidents; this includes peripheral neuropathy, hypoglycaemic events, foot ulcers or amputation, retinopathy, nephropathy, and sarcopenia. Drug-induced hypoglycaemia is one of the significant contributors to fall incidence; this is particularly prevalent in patients who are on sulfonylurea and/or insulin.¹

• To prevent these microvascular complications in patients with T2D, it is important to ensure a tight glycaemic control with HbA1c <7%. However, in elderly patients the targeted HbA1c is <8% as the risk of strict hypoglycaemic control tend to outweigh the benefits as it is associated with an increased risk of falls in this special population.²
• Insulin:
  • When insulin is indicated, ensure a regimen that mimics body’s natural insulin production baseline insulin (insulin glargine or insulin detemir) with short acting insulin at mealtime (insulin aspart, insulin lispro or insulin glulisine) to reduce the risk of hypoglycaemia.³
  • Consider administering basal insulin at night; there is some evidence to suggest that administering basal insulin in the morning is associated with less hypoglycaemic risk than evening dosing.⁴
• Sulfonylurea is associated with high risk of hypoglycaemia; they should be avoided when possible.^5,6
  
  • If the patient requires a sulfonylurea, then consider switching to gliclazide or glipizide as they are converted to inactive metabolites by the liver and are shorter acting—lower hypoglycaemic risk.^3,4,7
• Sodium/glucose co-transporter 2 (SGLT2) inhibitors:
  • Patients with T2DM who are treated with certain (SGLT2) inhibitors tend to have increased bone fragility and typical diabetic complications; this includes poor balance, diabetic retinopathy, impaired renal function and neuropathy have been associated with an increased risk of falls and fractures.¹
• Metformin
  
  • Can increase the risk of fall indirectly as it interferes with vitamin B₁₂ absorption leading to B₁₂ deficiency and thus neuropathy; this is dose dependent.
  • Consider dose reduction if B12 deficiency is detected.
  • High fall risk patients who are on long term metformin should be monitored for vitamin B₁₂ deficiency and provided with oral vitamin B₁₂ supplements when deficiency is detected.⁸
• Thiazolidinediones have a low risk of hypoglycaemia, yet they are still not recommended due to their safety profile. They should only be considered if the patient has a significant insulin resistance and/or when the avoidance of the hypoglycaemia risk is crucial.⁴
  
• Glucagon-Like Peptide-1 (GLP-1) analogues and dipeptidyl peptidase-4 (DPP-4) have a low risk of hypoglycaemia and thus they are associated with low fall risk. They can provide a benefit in high fall risk patients.⁴