Poll

An Older Woman at A1c Goal with Asymptomatic Hypoglycemia: What Next?

RM is an active 78-year-old woman with no complaints about her health or her medications. Then she tells you about her home blood glucose readings.

RM, a 78-year-old woman, presents to the clinic to establish care. Her past medical history is significant for type 2 diabetes (T2DM), hypertension, and atrial fibrillation. Current medications are:

Metformin          500 mg/bid                       Lisinopril         10 mg/day
Pioglitazone         45 mg/day                      Atorvastatin      10 mg/day  
Glyburide             10 mg/day                      Rivaroxaban     20 mg/day   
Metoprolol          100 mg/day
 

She states that she is happy with her current medications as all are “affordable” given her limited income and that it took her a long time to get her diabetes under control. Laboratory values include: HbA1c, 6.6%; basic metabolic panel, WNL (SCr, 1.2; eGFR, 45 mL/min). Vitals signs are: weight, 70kg; blood pressure, 126/72 mm Hg; pulse, 64. RM lives alone and tries to exercise 3 times per week and watches her diet. She notes that at least twice a week she obtains fasting blood glucose (FBG) readings <70 mg/dL but denies feeling poorly.

Would you adjust RM’s diabetes therapy?

A. Yes, discontinue pioglitazone due to high likelihood of hypoglycemia
B. No, her A1c is well controlled and she is not experiencing symptomatic hypoglycemia
C. Yes, discontinue glyburide and switch to an alternative sulfonylurea
D. No, her A1c is well controlled and she is not on therapy likely to cause hypoglycemia
E. Yes, increase glyburide to 20 mg daily to obtain a target A1c of <6.5%
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