A new article in the Journal of the American Medical Association (JAMA) is questioning whether controlling blood sugar in older adults with diabetes might do more harm than good.1
This is not to say that you are not better off with lower blood sugar. But, all things being equal, there are side effects and complications from drug treatments that may leave you worse off than just living with higherblood sugar once you become elderly.
Fortunately, that isn’t a choice you really need to make. You can lower your blood sugar safely—without Big Pharma’s new “wonder drugs.” More on that in a moment. But first, let’s take a look at this new study—and the dangers it uncovered.
New drugs TOO effective at lowering blood sugar?
So what’s the problem with drugs that treat high blood sugar?
Low blood sugar.
Diabetes drugs are designed to lower blood sugar. But sometimes they’re too “effective”—and drive blood sugar too low. This can be a real problem (especially in the elderly) because low blood sugar can cause fainting and dangerous falls.
Blood sugar fluctuates—going up and down before and after meals, with exercise, and daily cycles. Initially, blood sugar is measured after 12 hours of fasting to try to reduce these variations and find a “baseline” level. After that, doctors typically use Hemoglobin A1C to measure average blood sugar over the long term.
This test measures the level of hemoglobin that is bound to sugar in the blood. And it provides an average estimate of how high blood sugar gets in the blood, over an extended period of time.
Diabetes drugs lower your Hemoglobin A1C level over time. But this measurement really only gives you an average—and doesn’t account for times when your blood sugar goes too low.
So the authors of this new JAMA study suggest that the way diabetes is currently being treated in this country is a “one size fits all” approach leading to many adverse events.
On average, over a 10-year period, insulin (and new drugs that make the pancreas secrete insulin) will cause 4 to 7 severe episodes of low blood sugar in people who undergo this sort of therapy.
The older you are, the higher your risk of having a serious episode of low blood sugar. Taking multiple drugs (which also becomes more common as you age) adds to the problem—increasing your chances of another drug interacting with your diabetes medication and resulting in low blood sugar. And such episodes can have more serious consequences in older patients.
In fact, this study points out one of the biggest dangers of low blood sugar: Increased risk of dementia.
I have pointed out before that prolonged high blood sugar increases the risk of developing dementia.
(In fact, the problem is so serious, dementia can really be considered “Type 3 Diabetes.”)
But this new JAMA article indicates that low blood sugar is also a risk factor for dementia.
Old standby offers safe, effective blood sugar balancing
Of course, before you get scared away from diabetes drugs altogether, let’s make one thing clear. Not ALL blood sugar medications pose these risks.
It’s the expensive, newer drugs (still on patent) that appear to have the most worrisome complications.
Sulfonylureas (chlorpropamide, glipizide, glyburide, etc.) are the biggest offenders when it comes to frequent and prolonged episodes of low blood sugar (they also increase heart disease risk). Pioglitazone (commonly known as Actos) increases the risk of edema, heart failure, bladder cancer and osteoporosis. And newer, incretin-based drugs (like Victoza and Byetta) not only remain very expensive, but their long-term safety record still isn’t established.
But there are diabetes drugs that don’t cause these complications. Such as the old standby, Metformin, which is long proven to be safe and effective. The main “side effects” are decreased risks of other chronic diseases, such as cancer (including dramatic reductions in pancreatic cancer, which is notoriously untreatable).
Indeed, Metformin should be the therapy of choice for most patients. Except the FDA actually warns against Metformin treatment in patients over 80 years. This warning stems from the old red herring of lactic acidosis. This is a metabolic condition that results in a buildup of lactic acid in the muscles due to changes in levels of sugar and oxygen. In extreme cases this condition can be fatal.
But as the new JAMA study is quick to point out, this FDA precaution is not based on good quality evidence anyway. Studies have shown no difference in risk between diabetics using Metformin and those not using the drug. Most instances of this problem were actually due to underlying medical conditions among diabetic patients, and not the drug itself.
So the FDA warning against Metformin simply perpetuates an old, outdated myth. And it limits access to many older patients who could safely use Metformin. These are the very same patients who need it most—since they are the most vulnerable to episodes of low blood sugar and its effects (not to mention the potentially fatal side effects of the other, newer drugs.)
Are your health goals “age appropriate”?
The JAMA study also suggests revising Hemoglobin A1C levels upward based on increasing age.
This is an interesting idea. One that has been around for some time, for various conditions. For instance, when I was in medical training, the rule of thumb for “normal” systolic blood pressure was to add a patient’s age to 100. So at age 20 years, a normal blood pressure is 120/80. But at age 80, it climbs up to 180. Of course this was “normal” only in the sense of providing a rough statistical average in a population subjected to a lifetime of stress.
The bottom line is, any time you use drugs to achieve a therapeutic goal, there are always trade-offs.
And this new study suggests perhaps we can achieve a better trade-off between the effects of aging and the effects of drugs by setting somewhat more modest goals for everyone.
And recognizing that, among older Americans (like everyone), a balanced approach is most appropriate.
I couldn’t agree more.
Ultimately, just as persistent high blood sugar is associated with poor long-term health outcomes, so is low blood sugar. It is all about achieving balance in the body. Not too hot, not too cold, not too high, not too low.
The basic principle of homeostasis and metabolism.
And let’s not “experiment” with dangerous, unproven drugs in older Americans (or anyone else for that matter)…especially based on long-outdated, untrustworthy FDA “guidance.” As I’ve said before, Metformin remains the best, safest, and most economical drug treatment option for controlling high blood sugar.
Of course, if your blood sugar is only mildly elevated, you may be able to keep it under control with simple lifestyle modifications. Losing weight, exercising regularly, and eliminating sugar and processed foods from your diet can all go a long way in helping to balance blood sugar.
However, if your blood sugar is more than slightly elevated—or if you have full-blown diabetes—drug treatment is probably the best bet. Just stay away from the new diabetes drugs I warned you about above. Stick with the old—proven—standby, Metformin.
1. “Glucose Control in Older Adults With Diabetes Mellitus—More Harm Than Good?” JAMA Internal Medicine 2013; 173(14): 1,306-1,307