Managing Diabetes in Older Adults, Pregnancy, and with Steroid Use

Diabetes in Older Adults

• 🎯 Older adults with diabetes require relaxed A1C targets (7-8%) to prevent hypoglycemia, cognitive decline, and falls.
• ⚠️ Hypoglycemia can significantly worsen cognition and increase fall risk, making it crucial to avoid.
• 💡 Glucose tabs or tablets should be readily accessible, with family members advised to place them strategically throughout the home.
• 📉 De-escalating diabetes medications, especially sulfonylureas like glimepiride, is key if hypoglycemia or low blood sugars (<100) are observed.
• 📊 The 4 M framework (Mentation, Medications, Mobility, What Matters Most) is essential for tailoring diabetes care in older adults.

Gestational Diabetes and Pregnancy

• 🤰 Pregnancy necessitates stricter glucose targets: fasting 70-95 mg/dL and 2-hour postprandial 100-120 mg/dL.
• 🚫 GLP-1 agonists and SGLT2 inhibitors should be discontinued upon pregnancy discovery due to potential risks.
• 📈 Insulin is the preferred agent for managing diabetes during pregnancy, including gestational diabetes, type 1, and type 2 diabetes.
• 👁️ Women with diabetes planning pregnancy or who are pregnant require regular dilated eye exams to monitor for retinopathy.
• ⚠️ Postpartum, women with gestational diabetes have a 50% chance of developing type 2 diabetes within 5 years, necessitating weight management strategies.

Steroid-Induced Diabetes

• ⚡ Corticosteroids, particularly prednisone, significantly increase blood glucose, especially postprandially.
• 💉 Insulin therapy, often requiring dose adjustments, is the primary approach for managing steroid-induced hyperglycemia.
• 🔄 NPH insulin can be a useful tool, either replacing basal insulin or added to the regimen, due to its peak effect that can help manage postprandial spikes.
• 🔬 Continuous Glucose Monitors (CGMs) are invaluable for assessing glucose profiles and guiding insulin titration in complex cases.
• 🩺 For patients on long-term steroids, considering agents like GLP-1 agonists or SGLT2 inhibitors (if renal function allows) can be beneficial for postprandial control.