A 72-year-old widow has been living with Type 2 diabetes for 9 years. She is independently mobile and lives alone, although her family live nearby. She has been on her current medication metformin 1gm twice daily from diagnosis, and has been on gliclazide 160mg twice daily for seven years. She has not tried any other hypoglycaemic medication.

You receive a letter informing you that she attended the emergency room 5 days ago, having been found by her neighbour unconscious. In the emergency room she was found to have a capillary blood glucose reading of 2.3 mmol/L (41.4 mg/dl), was treated for hypoglycaemia and then sent home on her existing medication.

Her records show she had a diabetes review six weeks ago when her BP was 138/78 mmHg BMI 26.7 kg/m2; HbA1c 55 mmol/mol (7.2%); eGFR 68 mL/min/1.73 m2 and ACR 2.1 mg/mmol (18.5 mg/g) all of which have been stable for the past 3 years. Her hypertension is well controlled on ramipril 10mg and amlodipine 5mg ,and she takes atorvastatin 20 mg once daily.

Part A (50%)

1. What are the important actions you should take now in relation to her glucose lowering therapy?

Part B (50%)

2. Outline the pros and cons of the glucose-lowering medications she is currently on, what HbA1c target would you discuss with her?

Discussion should be based on the new guidelines and updated recommendations, like ADA and NICE

Also you can use the following resources:

https://www.openaccessjournals.com/articles/hypoglycemia-in-elderly-type-2-diabetes-patients.html

https://pmc.ncbi.nlm.nih.gov/articles/PMC4365959/#:~:text=Recurrent%20hypoglycemia%20is%20common%20in,both%20physical%20and%20cognitive%20dysfunction.

https://diabetesjournals.org/care/article/48/Supplement_1/S266/157556/13-Older-Adults-Standards-of-Care-in-Diabetes-2025