Mr B.H. is an 84-year-old retired farmer, new to your family practice and in the clinic for a medication review. He was recently assessed following a minor motor vehicle accident and diagnosed with vascular dementia (Montreal Cognitive Assessment score of 15 out of 30). Other medical problems include type 2 diabetes for more than 15 years, hypertension, coronary artery disease (coronary artery bypass graft 12 years ago), stable chronic heart failure, abdominal aortic aneurysm, chronic kidney disease (estimated glomerular filtration rate of 34 mL/min), benign prostatic hypertrophy, and chronic back pain. Medications include 5 mg of ramipril daily, 5 mg of amlodipine daily, 81 mg of acetylsalicylic acid daily, 20 mg of furosemide daily, 500 mg of metformin twice daily, 5 mg of glyburide twice daily, 10 mg of atorvastatin daily, and 500 mg of acetaminophen as needed. Mr B.H. lives with his elderly wife in their own home and is able to perform all basic activities of daily living. His appetite is adequate, but his wife and son note that in the past 6 months he forgets to eat regularly if not prompted. Laboratory results confirm good glycemic control with hemoglobin A_1c (HbA_1c) measurements of 7.2% and 7.4% in the past 8 months.

Metformin and glyburide are discontinued; Mr B.H. is started on 30 mg of gliclazide MR once daily. All other drug therapy remains unchanged. Care planning and the risks of overly tight diabetic control are discussed with the patient and his family. Home care nursing support is initiated for medication management and intermittent random BG testing. At a follow-up clinic visit in 3 months, nursing reports document random BG values of 4.6 to 12.8 mmol/L; Mr B.H.’s HbA_1c level is 7.9%. There have been no episodes of severe hypoglycemia, and Mr B.H. reports no concerns.

Mrs D.G. is a 79-year-old woman residing in a long-term care home after being hospitalized for a hip fracture that was treated surgically with arthroplasty. It has been 3 weeks since her surgery, and she is recovering well. Her family physician is contacted because the nurse is concerned about Mrs D.G.’s blood sugar levels, which have ranged from 3.3 mmol/L before lunch and supper to 10.6 mmol/L after some meals. Twice in the past week Mrs D.G. has required fruit juice to treat hypoglycemia. She has advanced rheumatoid arthritis with multiple joint deformities and decreased mobility. Other medical conditions include type 2 diabetes of more than 20 years’ duration, obesity (she weighs 80 kg and her body mass index is 31.2 kg/m²), hypertension, stable angina, chronic kidney disease (estimated glomerular filtration rate of 48 mL/min), osteoporosis, diabetic peripheral neuropathy, and early retinopathy. Mrs D.G.’s current diabetes therapy is 16 units of neutral protamine Hagedorn (NPH) insulin twice daily and 5 units of insulin lispro (Humalog) before meals (total daily insulin dose is 47 units per day). Before hospitalization, Mrs D.G. was taking 500 mg of metformin daily, 120 mg of gliclazide MR daily, and 20 units of NPH insulin at bedtime. Her diabetes control was “suboptimal” before the hip fracture (HbA_1c measurement taken 4 months ago was 8.2%), and she attributed this to the “excellent meals” provided in the assisted-living complex where she used to reside.

Metformin is resumed at 250 mg twice daily. The insulin dose is initially reduced to 8 units of NPH in the morning and at bedtime (0.2 units/kg/day), and 3 units of Humalog before breakfast and supper. Regular BG monitoring is implemented with further adjustment of insulin doses as needed, fixing lows first. With the reintroduction of metformin and a change in diet, Mrs D.G. requires less insulin than when in hospital. Her blood sugar levels are in the range of 8 to 12 mmol/L, and she has had no further episodes of hypoglycemia. The option of converting to a 30/70 premix (eg, Humulin 30/70, 10 units twice daily) is being considered.