What is the best management plan for a 70-year-old female patient with uncontrolled Type 2 Diabetes Mellitus (T2DM), hypertension, hyperlipidemia, osteoporosis, varicose veins, angina pectoris, and asthma?

Management Plan for 70-Year-Old Female with Uncontrolled Type 2 Diabetes

The optimal management plan for this 70-year-old female with Type 2 Diabetes (A1c 7.2%) should include continuing metformin 500 mg daily, adding a second 500 mg dose of metformin (preferably extended-release formulation to minimize GI side effects), discontinuing Jardiance, and maintaining glipizide, with a less stringent A1c target of <8.0% given her age and comorbidities. 1, 2

Assessment of Current Diabetes Control

• Patient is a 70-year-old female with multiple comorbidities including hypertension, hyperlipidemia, angina pectoris, asthma, osteoporosis, and varicose veins
• Current diabetes medications:
  • Metformin 500 mg once daily (reduced from twice daily due to abdominal pain)
  • Glipizide once daily (dose not specified)
  • Jardiance (empagliflozin) twice daily
• Most recent A1c: 7.2% (July 2025)
• Patient reports previous abdominal pain with higher metformin doses

Individualized A1c Target Recommendation

For this 70-year-old patient with multiple comorbidities:

• Recommended A1c target: <8.0% 1
• Rationale:
  • Advanced age (70 years)
  • Long-standing diabetes (approximately 14 years)
  • Multiple comorbidities including cardiovascular disease
  • History of medication intolerance
  • Risk of hypoglycemia with more intensive control

Medication Management Plan

1. Metformin adjustment:

   • Continue metformin as first-line therapy 2
   • Consider extended-release metformin to minimize GI side effects 3
   • Gradually increase to 1000 mg daily (500 mg twice daily or 1000 mg XR once daily) 2
   • Monitor for GI intolerance and adjust accordingly

2. Glipizide:

   • Continue current dose
   • Monitor for hypoglycemia, especially given patient's age

3. Jardiance (empagliflozin):

   • Discontinue as planned by PCP
   • While SGLT2 inhibitors have cardiovascular benefits 1, 4, this patient has reported intolerance to higher doses of metformin, suggesting optimization of current regimen is preferable before adding additional agents

4. Monitoring recommendations:

   • A1c testing every 6 months if stable, quarterly if therapy changes 1
   • Initiate home blood glucose monitoring to guide therapy adjustments
   • Regular monitoring of renal function, especially with metformin use

Management of Comorbidities

1. Cardiovascular disease:

   • Continue current antihypertensive regimen (Valsartan, Amlodipine, HCTZ)
   • Continue statin therapy (Atorvastatin) for lipid management 1
   • Consider aspirin therapy if no contraindication (note: patient has reported aspirin allergy)

2. Osteoporosis:

   • Evaluate bone mineral density
   • Consider calcium and vitamin D supplementation
   • Assess fall risk and implement prevention strategies

3. Varicose veins:

   • Continue compression stockings and leg elevation
   • Monitor for signs of venous insufficiency or ulceration, especially given diabetes 5

Lifestyle Modifications

• Dietary recommendations:

  • Consistent carbohydrate intake
  • Mediterranean or DASH eating pattern 1
  • Adequate hydration

• Physical activity:

  • Regular, moderate exercise appropriate for age and comorbidities
  • Start with walking program if not contraindicated
  • Consider physical therapy referral for hip and back pain

• Education:

  • Diabetes self-management education
  • Proper foot care and inspection
  • Recognition of hypoglycemia symptoms

Common Pitfalls to Avoid

1. Overly aggressive glycemic control in older adults can lead to hypoglycemia and falls 1

2. Therapeutic inertia - failing to intensify therapy when needed 2

3. Inadequate monitoring of vitamin B12 levels with long-term metformin use 2

4. Overlooking medication side effects - metformin can cause GI distress, but extended-release formulations may improve tolerability 3

5. Ignoring the risk of metformin-associated lactic acidosis in patients with renal impairment or during acute illness 6

This management plan prioritizes patient safety while working toward appropriate glycemic control, considering the patient's age, comorbidities, and medication tolerance history.