Family Medicine · Year 3 · from Family Medicine
Case 2: Diabetes with Hypoglycemia Concerns
Patient Demographics
- Age: 68 years old
- Sex: Female
- Occupation: Retired librarian
Chief Complaint
"I've been having shaky spells and I'm worried about my diabetes medicine."
History of Present Illness
Mrs. Eleanor Martinez is a 68-year-old woman with type 2 diabetes for 15 years who presents with recurrent episodes of shakiness, sweating, and confusion over the past month. These episodes occur 2-3 times weekly, typically mid-morning or before dinner. She has been checking her glucose during symptoms, which ranges from 52-68 mg/dL. Her daughter noticed her "acting confused" last week, and her glucose was 48 mg/dL. She has been taking her medications as prescribed. Her HbA1c 3 months ago was 6.1%.
She recently had decreased appetite due to a stomach bug 2 weeks ago and has been eating less since then. She also started a new blood pressure medication (metoprolol) 6 weeks ago.
Past Medical History
- Type 2 diabetes mellitus (15 years)
- Hypertension
- Chronic kidney disease stage 3b (eGFR 38)
- Atrial fibrillation
- Hypothyroidism
- Osteoporosis
Current Medications
- Glipizide 10mg twice daily
- Metformin 1000mg twice daily
- Lisinopril 20mg daily
- Metoprolol succinate 50mg daily
- Warfarin 5mg daily
- Levothyroxine 75mcg daily
- Alendronate 70mg weekly
- Calcium/Vitamin D
Family History
- Mother: Type 2 diabetes
- Father: Heart disease
Social History
- Never smoker
- No alcohol
- Widowed, lives alone
- Daughter lives nearby and checks on her daily
Physical Examination
- Vital Signs: BP 118/68 mmHg (sitting), 108/62 (standing), HR 62, BMI 26
- General: Thin elderly woman, appears anxious
- Cardiovascular: Irregularly irregular rhythm
- Neurologic: Alert, oriented, no focal deficits
- Extremities: No edema, mild peripheral neuropathy bilateral feet
Assessment and Diagnosis
- Recurrent hypoglycemia - Due to sulfonylurea in setting of reduced oral intake and declining renal function
- Type 2 diabetes with overtreatment - HbA1c 6.1% below target for this patient
- Chronic kidney disease stage 3b - Contributes to sulfonylurea accumulation
- Orthostatic hypotension - Possibly medication-related
Management Plan
For Hypoglycemia:
- STOP glipizide - Sulfonylureas are high-risk in elderly patients with CKD and unpredictable eating
- Continue metformin at reduced dose: 500mg twice daily (appropriate for eGFR 30-45)
- Relaxed glycemic target: HbA1c 7.5-8.0% for this elderly patient with comorbidities
- Hypoglycemia education for patient and daughter
- Glucagon emergency kit prescribed with teaching
For Blood Pressure:
- Given orthostatic hypotension, may need to reduce metoprolol
- Recheck BP with lying/standing measurements in 2 weeks
- Beta-blocker can mask hypoglycemia symptoms (tachycardia) - important counseling point
Safety Assessment:
- Discuss driving safety until hypoglycemia resolved
- Ensure patient has rapid-acting glucose available (glucose tablets)
- Daughter to call if patient seems confused
- Consider continuous glucose monitoring (CGM) if recurrent hypoglycemia
Follow-Up
- Phone check in 1 week to assess for hypoglycemia
- Return visit in 2-3 weeks
- Repeat HbA1c in 3 months (expect rise to 7-8%)
Teaching Points
- Glycemic targets in elderly: ADA recommends less stringent targets (HbA1c <8.0-8.5%) for older adults with limited life expectancy, multiple comorbidities, or high hypoglycemia risk. Overtreatment is harmful.
- Sulfonylureas and hypoglycemia risk: Sulfonylureas cause insulin secretion independent of glucose levels, leading to hypoglycemia risk, especially in elderly patients with CKD (reduced drug clearance) and irregular eating patterns.
- Beta-blockers and hypoglycemia: Beta-blockers can mask adrenergic symptoms of hypoglycemia (tachycardia, tremor) while preserving neuroglycopenic symptoms (confusion). Patients and families should recognize all hypoglycemia warning signs.
- Precipitants of hypoglycemia: Decreased oral intake, renal dysfunction (reduced drug clearance), and drug interactions can all precipitate hypoglycemia in previously stable patients.