Sulfonylureas in the elderly: Introduction

Last updated: June 11, 2020

This is Roopa. About 4 months ago she was diagnosed with diabetes. Initial attempts to manage her condition by diet and lifestyle alone were not sufficient, so metformin was prescribed. It  caused unpleasant gastrointestinal side effects, so Roopa refused to take it any more. As a result, she was started on gliclazide 80mg in the morning and given a blood glucose monitor with a card to record her levels.

After three weeks, her GP increased the dose to 80mg twice daily with meals because Roopa's blood glucose was still 9.4mmol/L. She was told to monitor her blood glucose until her next appointment.

Shortly after starting the new dose, Roopa developed a cold and lost her appetite. She continued to record her blood glucose levels in a little book that she had been given. The levels became progressively lower every day. She remembered that she had to "get below 8.5" after meals, and was pleased when she got to 8, and then 7 and then 5. At this stage, Roopa even wrote "very low" in her little book. She thought this was a good thing for her to to show the doctor at her next visit.

On the day after her blood glucose hit 5mmol/L, Roopa seemed rather anxious and 'not herself'; she was a bit shaky, sweaty, had a headache, and was irritable. But her husband thought it was due to her cold, and he was not worried when he left her to go out for a few hours. However, when he came home later, he found Roopa unconscious and called an ambulance.

Roopa was admitted to hospital where she was diagnosed with a hypoglycaemic coma. Despite attempts to correct the problem, sadly Roopa died a few hours after being admitted. She never regained consciousness.

  Why did a widely-used medicine for diabetes have such a devastating effect in this elderly patient?
  How could you have improved this patient's care and prevented a tragedy?

The answers to these two questions form the learning objectives for this tutorial. It should only take 20 minutes or so to read. You will probably already know a lot of it, but this is an opportunity to consolidate your learning. We adopt a concise and practical clinical approach.

Hypoglycaemia is not inevitable for people living with diabetes.

- Philip Newland-Jones, Consultant Pharmacist in Diabetes and Endocrinology

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