Diabetes Quiz 18

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.

Question 1

In addition to stopping glipizide and lowering insulin doses, you counsel the patient and his wife that his target HbA1C % and blood sugars should be which of the following:

A. HbA1C <6.0-6.5%, fasting/preprandial blood sugar 80-130 mg/dL
B. HbA1C <6.5-7.0%, fasting/preprandial blood sugar 80-130 mg/dL
C. HbA1C <7.5-8.0%, fasting/preprandial blood sugar 100-180 mg/dL
D. HbA1C <8.0-8.5%, fasting/preprandial blood sugar 100-180 mg/dL
Incorrect!
Correct!
Correct Answer
D. HbA1C <8.0-8.5%, fasting/preprandial blood sugar 100-180 mg/dL

Given this patient is elderly with multiple end stage chronic diseases, the goal of diabetes therapy is to minimize any significant hypoglycemic events that may be occurring. The target HbA1C can be adjusted to <8.0-8.5% in these patients with a less stringent fasting and preprandial blood sugar goal of 100-180 mg/dL. Since he has ESRD, sulfonylureas can predispose patients on dialysis to hypoglycemia and should be used very cautiously especially while on insulin therapy.

In older adults treatment goals for glycemic control should be modified over time based on comorbidities, functional and cognitive status, and patient/caregiver preferences.

Reference:

Standards of Care

12. Older Adults: Standards of Medical Care in Diabetes—2021

  1. American Diabetes Association

Diabetes Care 2021 Jan; 44(Supplement 1): S168-S179.https://doi.org/10.2337/dc21-S012

Given this patient is elderly with multiple end stage chronic diseases, the goal of diabetes therapy is to minimize any significant hypoglycemic events that may be occurring. The target HbA1C can be adjusted to <8.0-8.5% in these patients with a less stringent fasting and preprandial blood sugar goal of 100-180 mg/dL. Since he has ESRD, sulfonylureas can predispose patients on dialysis to hypoglycemia and should be used very cautiously especially while on insulin therapy.

In older adults treatment goals for glycemic control should be modified over time based on comorbidities, functional and cognitive status, and patient/caregiver preferences.

Reference:

​​​​​​​Standards of Care

12. Older Adults: Standards of Medical Care in Diabetes—2021

  1. American Diabetes Association

Diabetes Care 2021 Jan; 44(Supplement 1): S168-S179.https://doi.org/10.2337/dc21-S012