Step 1. Review Diabetes Regimen
Mr. A is 87 years old. He has type II diabetes mellitus and presents with a fall. His blood sugar at that time was 62 mg/dL. He lives in an assisted living facility and requires help with some ADLs, including bathing and dressing. Past medical history includes heart failure, urinary incontinence, and falls. His A1c = 7.2%, and his GFR = 48 mL/min.
Current Diabetes Regimen: Insulin glargine 20 units once daily and insulin aspart sliding scale (2–5) units with each meal.
Step 2. Individualize A1c Goal
- To individualize this patient’s A1c goal, according to the AGS and ADA guidelines, older adults with multiple comorbidities, poor health, and limited life expectancy should aim for an A1c goal of <8.5% (ADA) or <8–9% (AGS).
- Mr. A’s current regimen is overcorrecting his blood sugar (A1c = 7.2%), leading to hypoglycemia (62 mg/dL) and active adverse events (ie, falls).
Step 3. Discuss Patient Preferences
Mr. A and his provider discuss potential medication changes, and Mr. A says:
- “I want to avoid needles.”
- “I wish I could take fewer medications.”
Step 4. Determine What is Feasible
- Medication management: Consider medication management support at Mr. A’s assisted living facility (ie, supervised medication administration) and help with injections if needed.
- Comorbid conditions: Because Mr. A has heart failure, avoid TZD and saxagliptin. With his history of urinary incontinence may also avoid SGLT2i.
- Lower hypoglycemic risk: Replace sliding scale insulin, which is on the AGS Beers Criteria® list for risk of hypoglycemia, with metformin, an agent that has a glucose dependent mechanism of action.
Step 5. Deprescribe or Prescribe
- STOP using your insulin aspart sliding scale to lower the risk of low sugars.
- DECREASE your insulin glargine to 15 units once daily (25% reduction).
- START metformin 500 mg once daily and monitor for upset stomach.
- Repeat A1c in 3 months to determine if dose adjustments needed.
- Continue monitoring fasting blood sugars as able.