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Diabetes deintensification — USMLE Step 3 MCQ

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HardInternal Medicine (Chronic Management)Diabetes deintensificationUSMLE Step 3

A 79-year-old man with CKD stage 3b and mild cognitive impairment has A1c 6.2% while taking metformin and glyburide. Continuous glucose monitoring shows four overnight values below 54 mg/dL, and he twice required help from his daughter. Which medication plan is most appropriate?

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Correct answer: D — Stop glyburide and review glucose under a less stringent individualized target before replacing it

The best answer is “Stop glyburide and review glucose under a less stringent individualized target before replacing it”. Recurrent clinically important hypoglycemia outweighs the marginal benefit of very tight control in an older adult with CKD and cognitive vulnerability. Glyburide should be stopped and the target relaxed; glucose is then reassessed before another low-hypoglycemia-risk drug is added. Dose reduction, another sulfonylurea, or immediate insulin substitution can perpetuate avoidable hypoglycemia.

Reference: ADA Standards of Care: Older Adults: https://diabetesjournals.org/care/article/49/Supplement_1/S277/163917/13-Older-Adults-Standards-of-Care-in-Diabetes