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) 1000 milligrams (mg) twice daily?

From the Guidelines

The patient's metformin dose should be reduced to 500 mg twice daily to minimize the risk of further hypoglycemic episodes, as metformin is generally safe and effective but may cause hypoglycemia in elderly patients or those with decreased caloric intake 1. The recent fall due to hypoglycemia is concerning, especially since today's fasting blood sugar of 121 mg/dL is actually above the normal range, indicating possible rebound hyperglycemia. For a 65-year-old patient, less stringent glycemic targets are appropriate, with an A1C goal of 7.5-8.0% rather than the stricter targets used for younger patients 1. Some key points to consider in the management of this patient's diabetes include:

• Monitoring blood glucose levels more frequently, particularly before meals and at bedtime, and keeping a log of these readings
• Carrying fast-acting glucose (like glucose tablets or juice) at all times to treat any hypoglycemic symptoms
• A comprehensive medication review to check for other medications that might be contributing to hypoglycemia risk
• Considering the use of noninsulin agents, such as metformin, as first-line therapy for type 2 diabetes, with a dose adjustment based on renal function and tolerance 1. Given the patient's age and history of hypoglycemia, it is essential to prioritize their safety and adjust their treatment plan accordingly, with a focus on minimizing the risk of further hypoglycemic episodes and maintaining adequate blood glucose control 1.

From the FDA Drug Label

Insulin Secretagogues or Insulin Clinical Impact:Coadministration of metformin hydrochloride tablets with an insulin secretagogue (e.g., sulfonylurea) or insulin may increase the risk of hypoglycemia. Intervention:Patients receiving an insulin secretagogue or insulin may require lower doses of the insulin secretagogue or insulin.

The patient is on metformin 1000 mg twice a day and had a fall about a month ago from hypoglycemia. Hypoglycemia risk is a concern with metformin, especially when combined with other diabetes medications.

• The patient's current fasting blood sugar is 121, which is elevated.
• Dose adjustment of metformin or other diabetes medications may be necessary to minimize the risk of hypoglycemia.
• The patient should be closely monitored for signs of hypoglycemia, and education on hypoglycemia management should be provided 2.

From the Research

Patient's Current Condition

• The patient is a 65-year-old female who had a fall about a month ago due to hypoglycemia.
• Her current fasting blood sugar level is 121 mg/dL.
• She is taking metformin 1000 mg twice a day.

Hypoglycemia Management

• According to the study 3, hypoglycemia is a common issue in patients with diabetes and can be a major limiting factor in achieving glycemic control.
• The study 3 recommends a tailored approach to individualize glycemic goals and promote new therapies to improve the quality of life of patients.
• Continuous glucose monitoring (CGM) should be considered for individuals with increased risk for hypoglycemia, impaired hypoglycemia awareness, frequent nocturnal hypoglycemia, and a history of severe hypoglycemia 3.

Metformin and Hypoglycemia

• The study 4 found that the addition of sitagliptin to metformin and pioglitazone combination therapy improved glycemic control and was generally well-tolerated.
• The study 5 compared the efficacy and safety of sitagliptin and the fixed-dose combination of sitagliptin and metformin vs. pioglitazone in drug-naïve patients with type 2 diabetes, and found that the combination of sitagliptin and metformin was more effective in improving glycemic control.

Fasting and Hypoglycemia

• The study 6 found that patients with diabetes who are fasting for laboratory tests are at risk for hypoglycemia, and that a prevention program can reduce this risk.
• The study 7 found that short-term fasting lowers glucagon levels under euglycemic and hypoglycemic conditions in healthy humans, which could potentially increase susceptibility to hypoglycemia in patients with type 1 diabetes.

Considerations for the Patient

• The patient's current medication regimen and fasting blood sugar level should be taken into consideration when developing a plan to manage her hypoglycemia risk.
• The patient may benefit from continuous glucose monitoring (CGM) and a tailored approach to individualize her glycemic goals 3.
• The patient's healthcare provider should consider the potential risks and benefits of adjusting her medication regimen or adding new therapies to improve her glycemic control 4, 5.