Modern antidiabetic therapy in older adults with type 2 diabetes: evidence, best practice and a clinical pharmacist's...

Older adults with type 2 diabetes require treatment that balances cardiovascular and kidney protection against hypoglycemia, treatment burden, undernutrition, and functional vulnerability.

This narrative review considers PubMed-indexed literature and ClinicalTrials.gov records covering January 2010-October 2026, with targeted updating on 12 October 2026. It examines sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists, tirzepatide, and dipeptidyl peptidase-4 inhibitors. Age-stratified outcome evidence is distinguished from whole-trial results and the limited evidence in adults aged 80 years or older. Body-composition findings, neurodegenerative outcomes, kidney-protective treatment, and pharmacist-supported regimen modification are critically appraised.

Organ protection and glycemic simplification should be considered separately. Frailty is not synonymous with kidney impairment, and reductions in lean mass do not establish treatment-induced sarcopenia. Weight-neutral therapy remains useful when weight loss is undesirable. A structured medication review should integrate patient priorities, nutrition, physical performance, renal function, and hypoglycemia risk, followed by explicit monitoring and communication across care transitions. Prospective validation of this integrated framework in the oldest and most vulnerable populations is needed.