A 68-year-old with diabetes, CKD and two hypos who says "the numbers are good"
Mrs Ng, 68, has had type 2 diabetes for 18 years, hypertension and stage 4 chronic kidney disease. Her eGFR has fallen from 34 to 28 mL/min/1.73 m² over eight months and her urine albumin-to-creatinine ratio is 68 mg/mmol. Her current medication is metformin 1 g twice daily, gliclazide 80 mg twice daily, ramipril 10 mg daily, atorvastatin 20 mg and ibuprofen 400 mg as required for knee pain. HbA1c is 6.2%. She has had two episodes of symptomatic hypoglycaemia in the past month, one of which required her son to give her sugary drinks. She lives alone, cooks for herself, and has had two falls. She says she feels "fine" and is reluctant to change any medication because "the numbers are good". She asks whether she still needs to see the doctor so often now that everything is stable.
1. Which medications need to change today, and why?
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The HbA1c of 6.2% is not a good number in this patient; it represents over-treatment in someone with advanced CKD, frailty, falls and hypoglycaemia. The priority is to reduce harm, not to chase a lower figure.
- Stop metformin. It is contraindicated at an eGFR below 30 because of the risk of lactic acidosis, and her eGFR is 28 and falling. Continuing it offers little glucose-lowering benefit at this level of renal function.
- Reduce or stop gliclazide. Sulfonylureas and their metabolites accumulate in CKD, and her two symptomatic hypos - one needing rescue - are the clearest evidence of harm. Stopping it is likely to raise HbA1c modestly, which is acceptable and desirable here.
- Stop ibuprofen. NSAIDs reduce renal perfusion, worsen hypertension and albuminuria, and increase gastrointestinal bleeding risk. This may be contributing to the fall in eGFR. Replace with paracetamol and topical measures, and consider knee-strengthening advice.
- Continue ramipril. Despite the CKD, ACE inhibition reduces albuminuria and slows progression; I would check potassium, creatinine and blood pressure rather than stop it reflexively. If creatinine rises sharply after review, that changes the plan.
- Continue atorvastatin; age and CKD do not preclude it, though goals should reflect overall prognosis.
2. What glycaemic target and monitoring plan would you set?
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In an older adult with stage 4 CKD, recurrent hypoglycaemia, falls and living alone, the target should be relaxed. I would aim for an HbA1c of roughly 7.5–8.0%, and accept higher if she remains symptomatic or frail, rather than the 6.2% she currently has. The reasoning is that the benefit of tight control takes years to accrue, whereas the harm of a severe hypo - fracture, admission, brain injury - can happen tonight.
Monitoring should shift from HbA1c alone to a combination of:
- Home capillary glucose, particularly morning and pre-meal values, with a low threshold for testing if she feels unwell.
- Review of hypoglycaemia symptoms and whether she can recognise them; impaired awareness is common in long-standing diabetes and CKD.
- Renal function every three to six months, given the rate of decline.
- Blood pressure, potassium and albuminuria.
- Falls and functional review, including vision, footwear and home safety.
I would explicitly discuss with her that a higher HbA1c is safer for her and that "good numbers" are not the same as good health. I would involve her son in recognising and treating hypoglycaemia, and give a written plan rather than advice alone.
3. What CKD complications and referral issues should you address, and how do you answer her question about frequent visits?
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Stage 4 CKD with a rising albumin-to-creatinine ratio and rapid decline warrants active management and nephrology referral; an eGFR below 30 and an ACR above 70 mg/mmol are both standard referral triggers. I would explain that referral is to slow progression and prepare for the future, not to take over her care.
I would check:
- Haemoglobin and iron studies for renal anaemia.
- Calcium, phosphate, PTH and vitamin D for CKD–mineral bone disorder.
- Bicarbonate for metabolic acidosis.
- Potassium and creatinine after any ACE inhibitor change.
- Lipids and cardiovascular risk, since CKD is a cardiovascular risk equivalent.
- Vaccination status, including influenza and pneumococcal.
Medication review should also cover over-the-counter drugs, herbal remedies and contrast exposure, and she should understand sick-day rules for ramipril and any diuretic.
Her question about frequent visits deserves a direct answer: visits are not a sign that nothing is happening. They are how hypoglycaemia, falls and renal decline are caught before they become admissions. I would try to consolidate reviews, use nurse-led or telemedicine follow-up where available, and give her a written schedule so that the appointments feel purposeful rather than arbitrary.