A 68-year-old man with newly diagnosed type 2 diabetes mellitus on metformin 1000 mg twice daily and gliclazide (a sulfonylurea) has an HbA1c of 5.8% after six months; what is the next step in management?

Decrease the Dose (Option D)

For this 68-year-old man with HbA1c 5.8% on metformin 1000 mg BID plus gliclazide, the next step is to decrease or discontinue therapy—specifically, stop the gliclazide immediately to reduce hypoglycemia risk, as the HbA1c of 5.8% is below the recommended target and indicates overtreatment. 1

Rationale for Treatment De-intensification

• The American College of Physicians explicitly recommends considering de-intensification of pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%, as no trials show clinical benefit from targeting below this threshold and treatment to such low levels has substantial harms 1

• This patient's HbA1c of 5.8% is not only below the general target of <7.0% but also below 6.5%, placing him at increased risk for hypoglycemia without any demonstrated cardiovascular or microvascular benefit 1

• The ACCORD trial demonstrated that targeting HbA1c <6.5% was associated with increased overall and cardiovascular-related death and severe hypoglycemic events, leading to early trial discontinuation 1

Specific Medication Adjustment Algorithm

Step 1: Discontinue gliclazide immediately 1

• Sulfonylureas like gliclazide cause hypoglycemia and weight gain, and their continuation at this HbA1c level poses substantial harm without benefit 1
• The 2022 ADA/EASD consensus specifically states that agents causing hypoglycemia, such as sulfonylureas, should be discontinued when appropriate glycemic targets are achieved 1

Step 2: Continue metformin monotherapy 1

• Metformin should be maintained as the foundation of therapy due to its established safety profile, cardiovascular benefits, and lack of hypoglycemia risk when used alone 1
• Metformin is weight-neutral and does not increase hypoglycemia risk, making it appropriate for continued use even at lower HbA1c targets 1

Step 3: Monitor HbA1c in 3 months 1

• After discontinuing gliclazide, recheck HbA1c to ensure it remains in the appropriate target range of 7.0-8.0% for this 68-year-old patient 1
• If HbA1c rises above 7.5-8.0% on metformin alone, consider adding a medication with cardiovascular benefits such as a GLP-1 receptor agonist or SGLT2 inhibitor rather than restarting the sulfonylurea 1

Critical Safety Considerations

• At age 68, this patient may be at higher risk for hypoglycemia-related falls, cognitive impairment, and cardiovascular events—all of which are exacerbated by overly aggressive glycemic control 1

• The American College of Physicians guidance emphasizes that HbA1c targets in the range of 7.0-8.0% are appropriate for most patients, with lower targets (approaching 7.0%) reserved for those with newly diagnosed diabetes and no substantial complications 1

• For older adults, the 2022 ADA/EASD consensus recommends avoiding therapeutic inertia but also avoiding overtreatment, particularly with hypoglycemia-causing medications 1

Common Pitfalls to Avoid

• Do not continue both medications unchanged (Option A - Reassurance): This maintains unnecessary hypoglycemia risk and represents overtreatment 1

• Do not increase doses (Option B): Increasing medication doses when HbA1c is already below target would further increase hypoglycemia risk without any demonstrated benefit 1

• Do not add GLP-1 agonist (Option C): Adding another glucose-lowering agent when HbA1c is 5.8% would constitute dangerous overtreatment and is contraindicated 1

• Avoid the misconception that "lower is always better": The evidence clearly demonstrates that HbA1c <6.5% increases mortality risk without reducing macrovascular or microvascular complications 1