OBJECTIVES: Diabetes in the elderly is a major challenge both in terms of clinical management and of public health. Evidence about prescribing patterns in the elderly diabetic population is limited. The aim of the present study was to describe trends in antidiabetic drug (AD) utilization patterns in the elderly in Southern Italy with a focus on drugs for cardiovascular prevention and pharmaceutical costs. METHODS: The data used for this retrospective cross-sectional study was obtained from pharmacy records of Caserta Local Health Authority. Subject >65 years who received at least one dispensing of antidiabetic between January2010-December2014 were selected. Prevalence and incidence rates of AD use were calculated for each calendar year and stratified by class therapy and age group. Sub-analyses by cardiovascular co-medication therapy and pharmaceutical cost analysis were performed. RESULTS: Overall, the prevalence rate decreases from 22.0%-17.5% 2010-2014 (p<0.001).  Proportion of subjects treated with monotherapy increases over the study period (33,9%-38,6% 2010-2014; p<0.001). In particular, increases the proportion of users of metformin (18,2%-23,7% 2010-2014; p<0.001), while the proportion of users of sulfonylureas dropped (11,0%-7,2% 2010-2014; p<0.001). Overall about 90% of elderly diabetic patients are treated with drugs for cardiovascular prevention. The largest increase during the study period occurred in subjects aged 65-74 years (54.8%-62.1% 2010-2014; p<0.001). On the other hand the trend was downward both in the 75-84 and in ≥85 age groups   (37.3%-32.9% 2010-2014; 7.8%-5.0% 2010-2014 respectively). The per/patient/yearly drug costs was 2,349€: 28.5% for AD therapy and 71.5% for other treatments. CONCLUSIONS: The results confirm the negative trends observed in other population in the use of AD drugs among elderly diabetic patients. Specific trend in drug utilization patterns showed an increased attention towards treatment recommendations in older adults. Safety concerns in the elderly regarding polypharmacy such as presence of multimorbidity and hypoglycemic episodes could also have contributed to such a trend.