Title: Severe Sulfonylurea-Induced Hypoglycemia: A Case Report

Author(s): Rupalakshmi Vijayan, MD; Jon Arnott, MD

Email: rvijayan@mercy.com

Introduction: The American Geriatrics Society (AGS) released the 2023 update to the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

  • These include:
  • Over three dozen individual medications or medication classes to avoid for most older people.
  • 40+ medications or medication classes to use with caution or avoid for patients with certain diseases or conditions.

Methods/Case information:

  • A 74-year-old woman with a past medical history of atrial fibrillation, CHF, anemia, type 2 diabetes, and tobacco abuse, was evaluated in the ED for acute confusion.
  • She was found to have acute kidney injury and her blood glucose level was 45mg/dl
  • A review of medications revealed that she was taking glyburide 5 mg daily

Results/plan of management:

Plan for the patient:

  • Discontinuation of sulfonylurea
  • D10 infusion for 48 to 72 hours.
  • Monitor blood glucose every 2 hours
  • Cardizem drip for AF with RVR

Discussion/Conclusion:

  • At 74 years of age with a pre-existing history of heart disease and acute kidney injury on chronic kidney disease sulfonylureas are contraindicated.
  • The goals of the Beers criteria are to improve quality of care by reducing the use of inappropriate medications. They are also beneficial in education and research.
  • There has been beneficial evidence favoring GLP-1 receptor agonists and hereby evidence is being weighed in to make “avoid initiating sulfonylureas” a class recommendation. The panel is in the process of accumulating the evidence of harms greater in the elderly adults associated with the SGLT2 and DPP-4 inhibitors usage.
  • Even though hypoglycemic risk is lower with glipizide, glimepiride, when they occur are frequent and riskier in the elderly. This can reduce their safe usage in ages greater than 65 years.
  • Some causes of medication failure or side-effects is autonomic dysfunction. This is age-related and also caused by longstanding and uncontrolled diabetes
  • The glycated hemoglobin (HbA1c) target was raised up to 8.6% in elderly, does not justify the use of drugs that carry a risk of prolonged hypoglycemia.
  • Thus, old age (> 75 years), renal and liver disease are conditions in which sulfonylureas should not be used as first line therapy.
  • PPAR-Y agonists, SGLT-2 inhibitors, DPP-4 inhibitors are usually avoided in older age as well
  • It would be safer to consider low dose insulin maybe medium-long-acting insulin for >65 years age after careful consideration.