A 78 year old male presents to endocrine clinic for diabetes evaluation after recent hospital stay for a heart failure exacerbation. His past medical history is significant for ESRD on hemodialysis, HFrEF with an EF of 35%, CAD s/p multiple stents, COPD on home O2, hypertension, and hyperlipidemia.
His diabetes medication regimen is presently lantus 20 units qHS, lispro 7 units TID AC, and glipizide XL 10mg qday.
His wife is concerned about several low blood sugar readings since discharge from the hospital. He has had numerous blood sugar readings in the 50-60s mg/dL in the morning along with before meals during the day. He has classic hypoglycemic symptoms during these episodes.
Physical exam is significant for the following: BMI 28kg/M2 , BP 117/68mmHg, Heart rate 82bpm along with +2 pitting edema in the lower extremities bilaterally.
His most recent labs from 1 month ago were significant for a HbA1C of 5.9% and eGFR 7ml/minute/1.73m2.