What is the best next step for an 82-year-old woman with type 2 diabetes and hypertension, currently on insulin glargine, lisinopril, and simvastatin, with a Hemoglobin A1c of 7.0%?

Management of Diabetes in an 82-Year-Old Woman

The best next step for this 82-year-old woman with type 2 diabetes is to discontinue insulin glargine and consider starting a GLP-1 receptor agonist. 1, 2

Assessment of Current Status

This patient presents with:

• Age: 82 years
• Type 2 diabetes with HbA1c of 7.0%
• Current medications: insulin glargine 10 units daily, lisinopril 20 mg daily, simvastatin 20 mg daily
• No falls in past 2 years
• Independent living
• Normal timed up and go test
• MoCA score of 20/30 (indicating mild cognitive impairment)
• BMI of 30.2 (obesity)
• BP 125/82 mmHg (well-controlled)

Rationale for Discontinuing Insulin Glargine

1. Age-appropriate glycemic targets:

   • For older adults with multiple comorbidities, cognitive impairment, or functional dependence, less stringent glycemic goals (HbA1c <8.0–8.5%) are recommended 2
   • This patient's current HbA1c of 7.0% is already within an appropriate target range for her age and comorbidities

2. Hypoglycemia risk:

   • Older adults have a greater risk of hypoglycemia than younger adults 2
   • Insulin therapy increases this risk significantly, particularly in patients with cognitive impairment (MoCA 20/30)
   • Hypoglycemia can lead to falls, cognitive decline, and cardiovascular events in older adults

3. Simplified regimen:

   • Reducing the complexity of medication regimens is beneficial in older adults
   • Discontinuing insulin can improve quality of life by eliminating daily injections and glucose monitoring requirements

Alternative Treatment Options

GLP-1 Receptor Agonist Consideration

Starting a GLP-1 receptor agonist would be appropriate because:

• Provides effective glucose control with minimal hypoglycemia risk 1
• Offers weight reduction benefits (important with BMI 30.2) 1
• Has cardiovascular benefits in patients with type 2 diabetes 2
• Can be administered weekly (depending on formulation), improving adherence

Maintaining Lisinopril

The lisinopril should be continued because:

• Current blood pressure is well-controlled at 125/82 mmHg
• ACE inhibitors provide renoprotective effects in patients with diabetes 3, 4
• Lisinopril has been shown to slow progression of diabetic nephropathy 3
• No contraindications are present in this patient

Other Medication Considerations

• Simvastatin should be continued for cardiovascular protection
• If glycemic control worsens after insulin discontinuation, consider:
  • Metformin (if renal function permits)
  • DPP-4 inhibitor (well-tolerated with low hypoglycemia risk) 1

Implementation Plan

1. Gradual insulin withdrawal:

   • Reduce insulin dose by 50% initially
   • Monitor fasting glucose levels for 1-2 weeks
   • Complete discontinuation if glucose levels remain stable

2. Close follow-up:

   • Schedule follow-up within 2 weeks for initial adjustment
   • Monthly visits until stable
   • Assess adequacy of therapy after 3 months 1

3. Monitoring parameters:

   • Fasting and random glucose levels
   • Symptoms of hyperglycemia
   • Weight changes
   • Signs of hypoglycemia

Potential Pitfalls and Caveats

1. Hyperglycemia after insulin discontinuation:

   • While some increase in glucose may occur, the target HbA1c for this patient can be relaxed to 8.0-8.5%
   • Hyperglycemia leading to symptoms should still be avoided 2

2. Medication adherence:

   • Assess ability to manage new medication regimen
   • Consider once-weekly GLP-1 RA formulations to improve adherence

3. Cost considerations:

   • GLP-1 RAs are more expensive than insulin
   • Check insurance coverage and consider patient's financial situation

4. Monitoring cognitive function:

   • The MoCA score of 20/30 indicates mild cognitive impairment
   • Simplifying the medication regimen becomes even more important
   • Involve the patient's daughter in medication management discussions

By discontinuing insulin glargine and considering a GLP-1 receptor agonist, we prioritize reducing hypoglycemia risk while maintaining adequate glycemic control, which directly addresses the most important outcomes of reducing morbidity, mortality, and improving quality of life in this elderly patient.