Yes, Discontinue Glipizide in This 82-Year-Old Patient
You should discontinue glipizide in this 82-year-old patient with an A1c of 6.8% on Ozempic, as this represents overtreatment that increases mortality risk and hypoglycemia without providing clinical benefit. 1
Why Glipizide Must Be Stopped
The A1c is Dangerously Low for This Patient
An A1c of 6.8% in an 82-year-old patient requires immediate deintensification of therapy. The American College of Physicians explicitly states that when patients achieve A1c levels below 6.5%, clinicians should deintensify treatment by reducing dosage, removing a medication if the patient is receiving more than one, or discontinuing pharmacologic treatment entirely. 1
The ACCORD trial, which targeted A1c levels below 6.5% (achieving 6.4%), was discontinued early due to increased overall and cardiovascular-related death and severe hypoglycemic events. 1
For patients aged 80 years or older, the American College of Physicians recommends treating to minimize symptoms rather than targeting specific A1c levels, because the harms outweigh the benefits in this population. 1
Age-Specific Guidelines Support Less Intensive Control
The American Diabetes Association recommends that older adults aged 80+ with few coexisting chronic illnesses should target A1c <7.5%, while those with multiple conditions should target A1c 8.0-8.5%. 1
Even for the healthiest 82-year-old patients, an A1c of 6.8% is below the recommended target and provides no additional benefit while substantially increasing harm. 1
The rationale is clear: any benefit of intensive glycemic control requires at least 10 years to manifest, and modeling studies show that achieving A1c targets below 7.5% in patients aged 55 years or older results in net harm when considering treatment burden and adverse effects. 1
Which Medication to Remove: Glipizide
Glipizide Has the Highest Risk Profile
Sulfonylureas like glipizide are associated with significant hypoglycemia risk and should be used with extreme caution in older adults. 1
The American College of Cardiology specifically recommends discontinuing sulfonylureas first when patients experience hypoglycemia or are overtreated, as they directly stimulate insulin secretion regardless of blood glucose levels. 2
Glyburide (a related sulfonylurea) is explicitly contraindicated in older adults, and while glipizide is shorter-acting, it still carries substantial hypoglycemia risk in this age group. 1
Ozempic Should Be Continued
Ozempic (semaglutide) provides significant cardiovascular benefits beyond glucose control, with the SUSTAIN 6 trial demonstrating reduced major adverse cardiovascular events. 3
GLP-1 receptor agonists like Ozempic have minimal hypoglycemia risk when used without sulfonylureas or insulin. 3
The cardiovascular and potential renal protective benefits of Ozempic are particularly important for older adults, whose mortality is more influenced by cardiovascular risk factors than tight glycemic control. 1
Implementation Strategy
Immediate Action
Stop glipizide immediately without tapering, as sulfonylureas do not require gradual discontinuation. 2
Continue Ozempic at the current dose, as it is providing effective glycemic control with cardiovascular benefits. 3
If the patient is also on metformin, continue it as well, since metformin is not associated with hypoglycemia and provides cardiovascular benefits independent of glucose control. 1
Monitoring Plan
Check fasting and random glucose levels weekly for 3-4 weeks after discontinuing glipizide to ensure the patient does not develop symptomatic hyperglycemia. 2
Recheck A1c in 3 months, with a target range of 7.5-8.0% for this 82-year-old patient. 1
If A1c rises above 8.5%, consider optimizing the Ozempic dose (up to 2.0 mg weekly if needed) rather than restarting glipizide. 4
Critical Pitfalls to Avoid
Do Not Continue Dual Therapy at This A1c Level
Continuing both Ozempic and glipizide with an A1c of 6.8% constitutes dangerous overtreatment in an 82-year-old patient and directly contradicts evidence-based guidelines. 1
The combination of a GLP-1 receptor agonist with a sulfonylurea increases hypoglycemia risk without providing benefit at this A1c level. 3
Do Not Reduce Ozempic Instead
Reducing or stopping Ozempic would eliminate its cardiovascular protective effects, which provide greater mortality benefit than tight glycemic control in older adults. 1, 3
Studies comparing GLP-1 receptor agonists to insulin glargine in patients with A1c >9% showed that GLP-1 receptor agonists provided superior or equivalent A1c reduction, demonstrating their potency even as monotherapy. 5