Canadian Diabetes & Endocrinology Today

Aging In The Face of Diabetes: Severe Hypoglycemia in Older Adults

Alexandria Ratzki-Leewing — 2024-08-30

Global rates of type 1 and type 2 diabetes (T1D, T2D) continue to climb, despite medical advancements. Older adults constitute one of the fastest growing segments of the diabetes population, backed by the world’s unprecedented aging population, decreased diabetes mortality rates, and the obesity epidemic. In Canada, individuals aged ≥65 years account for more than a quarter of all prevalent diabetes cases, far exceeding the other age groups.

Older adults with diabetes face the highest risks of microvascular and macrovascular complications, which, compared to younger age cohorts, can contribute to significant functional loss, frailty, and premature mortality. A considerable amount of research links intensive glucose-lowering with insulin or secretagogues to reduced cardiovascular disease. However, the consequent risk of severe hypoglycemia and related sequelae can be particularly catastrophic for older adults, exacerbated by coexisting health conditions and age-related social needs.

Approximately 40% of Canadians with T2D aged ≥65 years currently use secretagogues, while 27% use insulin—alongside all those with T1D. Longitudinal evidence suggests that since the year 2000, hospital admission rates for hypoglycemia have consistently surpassed those for hyperglycemia, especially among individuals aged 75 years and above. Economic modelling estimates that the Canadian healthcare system spends $125,932 CAD per year on iatrogenic hypoglycemia, with the bulk of these costs likely allocated to people ≥65 years.

Diabetes in older adults is a pressing public health issue in Canada, marked by clinical diversity and widespread use of medications that are prone to cause hypoglycemia. This review outlines recent epidemiologic findings on severe hypoglycemia among community-dwelling older adults with T1D or T2D treated with insulin or secretagogues. Understanding the complex factors contributing to severe hypoglycemia in this population is crucial for developing tailored prevention strategies that are both effective and safe.

Obstructive Sleep Apnea and Type 2 Diabetes

Aaron LeBlanc — 2024-08-30

Obstructive sleep apnea (OSA) and type 2 diabetes (T2D) are commonly encountered diseases in clinical practice, and there appears to be a bidirectional relationship between these 2 diseases. The presence of OSA can increase the risk of developing T2D, increase the risk of micro- and macro-vascular complications, and increase the risk of mortality. Several management strategies are available that can positively impact the outcomes of patients living with co-existing T2D and OSA. Given this bidirectional relationship, the negative consequences of untreated OSA on outcomes in T2D, along with the currently available management strategies, screening for OSA in patients with T2D should be considered.

A Practical Approach to the Incidental Adrenal Mass

Neal Rowe — 2024-08-30

With modern use of abdominal imaging, incidental detection of adrenal masses is increasingly common. These lesions are estimated to be present in 4% of all patients and in up to 10% of the elderly population. Fortunately, most adrenal masses are benign non‑functioning adenomas. However, some of these lesions are hyperfunctioning or harbour malignancy. A familiarity with the evaluation and management of incidental adrenal masses is of interest to endocrinologists as well as surgeons and primary care providers who order abdominal imaging tests.

In 2023 a multidisciplinary working group of Canadian radiologists, endocrinologists, and radiologists published an updated guideline on the diagnosis, management, and follow‑up of the incidentally discovered adrenal mass.⁴ This publication has helped clarify the necessary imaging and biochemical testing required prior to creating a management plan for a patient with an incidental adrenal lesion.

When faced with an adrenal mass, the clinician must answer 3 essential questions: 1) Is the mass benign or malignant? 2) Is the mass hormonally functional or non-functional? 3) How should the mass be managed?

Finerenone in Diabetic Kidney Disease

Adam Cohn — 2024-08-30

Diabetic kidney disease (DKD) affects 40% of individuals with diabetes mellitus (T2DM) and is associated with an increased risk of cardiovascular events, hospitalization for heart failure, and premature death. Existing treatments focus on lifestyle measures, glycemic control, blood pressure and lipid management, inhibition of the renin‑angiotensin‑aldosterone system (RAAS), and the use of sodium glucose cotransporter 2 inhibitors (SGLT2-i). However, substantial residual risk of progression to end-stage kidney disease (ESKD) or cardiovascular complications remain despite optimal therapy. Finerenone, a non-steroidal mineralocorticoid antagonist (MRA), has been shown to reduce important outcomes when added to evidence-based therapies, and is approved by Health Canada as an adjunct to standard of care therapy in adults with chronic kidney disease (CKD) and T2DM to reduce the risk of ESKD and a sustained decrease in estimated glomerular filtration rate (eGFR), cardiovascular death, non-fatal myocardial infarction, and hospitalization for heart failure.