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Hypoglycemia in type 2 diabetes

Case description Judith is a 72-year-old woman whom you are seeing for the first time while working as a locum physician in a family medicine clinic. She reports having had T2DM for 20 years. She is concerned because most days she needs to eat a snack midafternoon and again a couple of hours after supper to prevent symptoms of hypoglycemia and her blood glucose levels decreasing below 4.5 mmol/L. This started a few months ago, and she is not happy with the associated weight gain. She also wakes during the night with sweats (“Just like when I went through menopause”) and feeling hungry. She usually goes back to sleep after having a glass of milk and crackers. She has no other new health concerns. Her recent blood glucose test results include the following: before breakfast or fasting, 5.4 to 9.8 mmol/L; before lunch, 5.3 to 8.4 mmol/L; before supper, 4.2 to 8.6 mmol/L; and at bedtime, 8.0 to 10.2 mmol/L. On further inquiry, Judith informs you that she received formal diabetes education 10 years ago when she started basal insulin; she has not seen an educator since then and was not aware that she could adjust her insulin doses. Her current diabetes medications (unchanged for the past couple of years) include 850 mg of metformin, twice daily; 26 units of insulin neutral protamine Hagedorn (NPH), twice daily in the morning and at bedtime; and 10 units of insulin lispro, 3 times daily before each meal. Her other medical conditions include hypertension for more than 20 years; dyslipidemia; mild obesity (body mass index of 32.9 kg/m2, weight of 80 kg, height of 156 cm); osteoarthritis of the hips, knees, and lumbar spine; chronic low back pain; diabetic nephropathy; stable nonproliferative diabetic retinopathy; and mild sensory diabetic peripheral neuropathy. She quit smoking 15 years ago. Judith lives on her own in an apartment; she performs all her activities of daily living, but physical activity is limited by her arthritis and chronic back pain. She uses a 4-wheeled walker when outside her apartment. She no longer drives. Her Clinical Frailty score is 5 (functionally dependent).1 Other medications for Judith include 50 mg of chlorthalidone daily, 100 mg of losartan daily, 10 mg of amlodipine daily, 10 mg of rosuvastatin daily, acetaminophen as needed for back pain, 2000 IU of vitamin D daily, a daily multivitamin, 500 mg of glucose sulfate 3 times daily, and 500 mg of calcium carbonate daily. Recent laboratory test results include normal findings for complete blood count, with a hemoglobin level of 110 g/L; normal electrolyte levels; a serum creatinine level of 149 μmol/L, with an estimated glomer ular filtration rate (eGFR) of 30 mL/min; a urine albumin to creatinine ratio of 209.46 μg/mmol; a glycated hemoglobin A1c (HbA1c) level of 7.8%; a lipid profile including total cholesterol of 2.94 mmol/L, a triglyceride level of 1.09 mmol/L, a high-density lipoprotein level of 0.95 mmol/L, a low-density lipoprotein level of 1.49 mmol/L, and a non–high-density lipoprotein level of 1.99 mmol/L; and a thyroid-stimulating hormone level of 2.87 mIU/L. Reviewing the provincial laboratory result database you note that HbA1c results have been in the 7.8% to 8.5% range in the past 2 years, and eGFR has declined from 45 mL/min 12 months ago to 30 to 34 mL/min on 3 tests in the past 6 months. Her creatinine clearance is 38 mL/min. Why is Judith experiencing hypoglycemia, and how would you address her concerns?