What is the appropriate management for a 65-year-old female with a history of fall due to hypoglycemia, currently presenting with impaired fasting glucose, and taking metformin (Metformin) 100 milligrams (mg) twice daily?

From the Guidelines

The patient's current metformin dose of 100 mg twice daily should be increased to the standard starting dose of 500 mg daily, as tolerated, to improve glycemic control, as recommended by the most recent guidelines 1. The patient's hypoglycemic fall and current elevated fasting blood sugar of 121 mg/dL indicate a need to adjust her diabetes management. I recommend increasing her metformin dose and implementing more frequent blood glucose monitoring. The current metformin dose is unusually low, suggesting possible medication error or confusion. The patient should check her blood glucose 3-4 times daily, including before meals and at bedtime, and maintain a log of these readings. A continuous glucose monitor would be ideal to detect hypoglycemic episodes. Dietary modifications are also important - she should consume regular, balanced meals with consistent carbohydrate intake and carry fast-acting glucose sources (like glucose tablets or juice) to treat hypoglycemia. The hypoglycemic fall suggests her medication may be too potent for her needs, while the elevated fasting glucose indicates suboptimal diabetes control. This contradiction points to possible glucose variability that needs careful management to prevent both hypoglycemic episodes and long-term complications from hyperglycemia. A comprehensive diabetes evaluation with an endocrinologist is warranted to optimize her treatment plan, considering the latest guidelines on pharmacologic approaches to glycemic treatment 1 and glycemic targets 1. Additionally, the patient's nutrition therapy should be guided by the recommendations for the management of adults with diabetes, emphasizing portion control, carbohydrate counting, and balanced meals 1.

Some key points to consider in her management include:

• Increasing metformin dose to 500 mg daily, as tolerated, to improve glycemic control 1
• Implementing more frequent blood glucose monitoring to detect hypoglycemic episodes and adjust treatment accordingly 1
• Dietary modifications to consume regular, balanced meals with consistent carbohydrate intake and carry fast-acting glucose sources to treat hypoglycemia 1
• Comprehensive diabetes evaluation with an endocrinologist to optimize her treatment plan, considering the latest guidelines on pharmacologic approaches to glycemic treatment 1 and glycemic targets 1

From the FDA Drug Label

2 DOSAGE AND ADMINISTRATION

1. 1 Adult Dosage Metformin Hydrochloride Tablets The recommended starting dose of metformin hydrochloride tablets are 500 mg orally twice a day or 850 mg once a day, given with meals. Increase the dose in increments of 500 mg weekly or 850 mg every 2 weeks on the basis of glycemic control and tolerability, up to a maximum dose of 2550 mg per day, given in divided doses.

The patient is currently taking metformin 100 mg twice a day, which is lower than the recommended starting dose of 500 mg orally twice a day or 850 mg once a day.

• The patient's current dose is not within the recommended dosing range.
• Considering the patient's fasting blood sugar is 121, the dose may need to be adjusted to achieve better glycemic control.
• However, given the patient's history of hypoglycemia, any changes to the medication regimen should be made with caution to avoid exacerbating the condition 2.

From the Research

Patient Profile

• The patient is a 65-year-old female who experienced a fall about a month ago due to hypoglycemia.
• Her current fasting blood sugar is 121, and she is taking metformin 100 mg twice a day.

Relevant Studies

• A study published in 2014 3 found that hypoglycemia-induced falls are common in older persons with diabetes, and that metformin is a suitable first-choice drug for this population due to its low risk of causing hypoglycemia.
• Another study from 2014 4 compared the glucose-lowering effects of a GLP-1 receptor agonist (liraglutide) and a sulfonylurea (glimepiride) in patients with maturity-onset diabetes of the young, and found that liraglutide had a lower risk of hypoglycemia.
• A review of glucose-lowering medicines for type 2 diabetes published in 2015 5 recommended metformin as the first choice for most patients, due to its proven benefits and low risk of hypoglycemia.
• A study published in 2015 6 found a significant association between hypoglycemia and fall-related events in elderly patients with type 2 diabetes, highlighting the importance of avoiding hypoglycemia in this population.
• A randomized controlled trial published in 2014 7 compared the GLP-1 receptor agonist liraglutide to a sulphonylurea as add-on to metformin in patients with established type 2 diabetes, and found that liraglutide was well-tolerated and effective in achieving target HbA1c levels with no severe hypoglycemia.

Key Findings

• Metformin is a suitable first-choice drug for older patients with diabetes due to its low risk of causing hypoglycemia 3, 5.
• Hypoglycemia is a significant risk factor for fall-related events in elderly patients with type 2 diabetes 6.
• GLP-1 receptor agonists such as liraglutide may be a suitable alternative to sulfonylureas due to their lower risk of hypoglycemia 4, 7.