Does your elderly (>65 years of age) patient with type 2 diabetes meet one or more of the following criteria:

At risk of hypoglycemia (e.g. due to advancing age, tight glycemic control, multiple comorbidities, drug interactions, hypoglycemia history or unawareness, impaired renal function, or on sulfonylurea or insulin)
Experiencing, or at risk of, adverse effects from antihyperglycemic
Uncertainty of clinical benefit (due to: frailty, dementia or limited life-expectancy)

Yes

No

End

Still at risk?

Continue Antihyperglycemic(s)

Recommend Deprescribing

Reduce dose(s) or stop agent(s)

most likely to contribute to hypoglycemia (e.g. sulfonylurea, insulin; strong recommendation from systematic review and GRADE approach) or other adverse effects (good practice recommendation)

with lower risk of hypoglycemia (e.g. switch from glyburide to gliclazide or non-sulfonylurea; chnage NPH or mixed insulin to determir or glargine insulin to reduce nocturnal hypoglycemia; strong recommendation from systematic review and GRADE approach)

of renally eliminated antihyperglycemics (e.g. metformin, sitagliptin; good practice recommendation) - See guideline for recommended dosing

most likely to contribute to hypoglycemia (e.g. sulfonylurea, insulin; strong recommendation from systematic review and GRADE approach) or other adverse effects (good practice recommendation)

with lower risk of hypoglycemia (e.g. switch from glyburide to gliclazide or non-sulfonylurea; chnage NPH or mixed insulin to determir or glargine insulin to reduce nocturnal hypoglycemia; strong recommendation from systematic review and GRADE approach)

of renally eliminated antihyperglycemics (e.g. metformin, sitagliptin; good practice recommendation) - See guideline for recommended dosing

Monitor daily for 1-2 weeks after each change (TZD - up to 12 weeks):

For signs of hyperglycemia (excessive thirst or urination, fatigue)
For signs of hypoglycemia and/or resolution of adverse effects related to antihyperglycemic(s)

Increase frequency of blood glucose monitoring if needed
A1C changes may not be seen for several months

If hypoglycemia continues and/or adverse effects do not reslove:

Reduce dose further or try another deprescribing strategy

If symptomatic hyperglycemia or blood glucose exceeds individual target:

Return to previous dose or consider alternate drug with lower risk of hypoglycemia

Yes

No

Set individualized A1C and blood glucose (BG) targets (otherwise healthy with 10+ years life expectancy, A1C < 7 % appropriate; considering advancing age, frailty, comorbidities and time-to-benefit, A1C < 8.5% and BG < 12mmol/L may be acceptable; at end-of-life, BG < 15mmol/L may be acceptable) (good practice recommendation)

Address potential contributors to hypoglycemia (e.g. not eating, drug interactions such as trimethoprim/sulfamethoxazole and sulfonylurea, recent cessation of drugs causing hyperglycemia - see reverse)