Sulfonylurea overtreatment in frailty — SCE Geriatric Medicine MCQ

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HardEndocrine medicineSulfonylurea overtreatment in frailtySCE Geriatric Medicine

A 78-year-old man with type 2 diabetes, osteoarthritis and frailty is reviewed after two hypoglycaemic episodes and a fall. His HbA1c is 47 mmol/mol, eGFR is 38 mL/min/1.73 m² and BMI is 21 kg/m². Medication includes gliclazide 160 mg twice daily, metformin 500 mg twice daily, ramipril, atorvastatin and codeine. What is the most appropriate management?

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Correct answer: E — Reduce or stop gliclazide and agree an individualised glycaemic target

The correct answer is **A**. This patient has experienced overt harm from overtreatment: two hypoglycaemic episodes and a fall. His HbA1c of 47 mmol/mol is already below or at the lower end of the recommended range (58–64 mmol/mol) for frail older people with multimorbidity. The high-dose gliclazide (160 mg BD) is the primary culprit—sulfonylureas carry substantial hypoglycaemia risk, especially in frailty. Combined with reduced renal function (eGFR 38) and low BMI, the risk of drug accumulation and hypoglycaemic harm is substantial. **Option B** misinterprets the HbA1c diagnostic threshold (48 mmol/mol) as a treatment target; in frailty, lower HbA1c is not beneficial and increases harm. **Option C** adds a new agent without de-intensifying the existing overtreatment. **Option D** wrongly attributes falls to atorvastatin rather than the clear hyperglycaemia-induced problem. **Option E** worsens hypoglycaemia risk by introducing insulin. The solution is individualised de-intensification: reduce/stop the sulfonylurea and establish a relaxed glycaemic target in line with the patient's frailty, life expectancy, and functional status—a core principle of modern UK diabetes care in older age.

Reference: Southwest London ICB (September 2024). Type 2 Diabetes & Frailty Prescribing Guideline. https://swlimo.southwestlondon.icb.nhs.uk/wp-content/uploads/Type-2-diabetes-prescribing-in-frailty-v1.1-September-2024.pdf; supported by NICE, NHS Scotland Right Decisions, and Royal Berkshire Hospital (2025) quality improvement evidence.