Preventing the preventable: Clinical pharmacy role in managing severe hypoglycemia in an elderly patient on glimepride

Shirlin M.S^1*, Vignesh R¹, Johnson²

¹Clinical Pharmacist, Kauvery Hospital, Heartcity, Trichy, Tamil Nadu

²Group Clinical Pharmacist, Kauvery Hospital, Heartcity, Trichy, Tamil Nadu

*Correspondence

Abstract

Hypoglycemia is a major adverse drug reaction associated with sulfonylurea therapy, particularly in elderly patients with multiple comorbidities. We report a case of an 81-year-old male with extensive coronary artery disease and type 2 diabetes mellitus who developed severe hypoglycemia following escalation of glimepiride-containing therapy. The case highlights the importance of individualized glycemic targets, clinical pharmacy intervention, and discharge counseling to prevent medication-related harm.

Keywords: Sulfonylurea; Hypoglycemia; Glimepiride; Elderly diabetes; Clinical pharmacy; Coronary artery disease

Introduction

Type 2 diabetes mellitus (T2DM) in elderly patients requires careful pharmacologic selection due to increased susceptibility to adverse drug reactions, particularly hypoglycemia. Sulfonylureas such as glimepiride stimulate insulin secretion independent of glucose levels and are associated with increased risk of hypoglycemia, especially in older adults and those with comorbid cardiovascular disease. Clinical pharmacy interventions improve medication safety by identifying drug-related problems and optimizing therapy.

Case Presentation

An 81-year-old male with a history of hypertension and diabetes presented with significant cardiovascular disease, Acute coronary syndrome (inferior wall, right ventricular, posterior wall myocardial infarction), Triple vessel disease, Complete heart block (temporary pacemaker inserted on 09/03/2023 and removed), Dyslipidemia, mild left ventricular systolic dysfunction, EF 45%, dilated LA, grade I diastolic dysfunction, mild MR/TR and mild PAH. Patient underwent Primary PTCA with stenting to proximal and mid RCA and Elective PTCA with stenting to mid LAD in March 2023 and discharged with Dual antiplatelet therapy, Atorvastatin, Beta-blocker and Glycomet-GP (metformin + glimepiride 0.5 mg BD).

Disease Progression

2024: FBS 87 mg/dL, PPBS 158.6 mg/dL, HbA1c level not known.
2025: FBS 95.4 mg/dL, PPBS 224 mg/dL, HbA1c 7.6%

Due to worsening glycemic control, glimepiride dose was escalated to 2 mg at night and 1mg in the morning. In addition, Glycomet 500mg was prescribed in the morning.

Adverse Event

Five days after dose escalation (March 2026), the patient developed giddiness, weakness, fatigue and confusion early in the morning. Capillary blood glucose was 45 mg/dL, and symptoms improved after oral sugar intake.

Assessment: The hypoglycemic episode is a probable, dose-related adverse drug reaction to glimepride. Hence diagnosed as severe symptomatic hypoglycemia.

Clinical Pharmacy Intervention

Prescription Review

Identification of sulfonylurea-associated hypoglycemia risk
Assessment of appropriateness of dose in elderly patient
Recommendation for therapy reassessment

Comparative Safety Profile of Antidiabetic Drug Classes

Sulfonylureas are insulin secretagogues widely used for effective blood glucose lowering, they are associated with a significantly higher risk of hypoglycemia compared to other antidiabetics. This risk is particularly pronounced in elderly patients, those with cardiovascular disease, and individuals with fluctuating dietary intake or renal impairment.

Table: Hypoglycemia Risk and Key Safety Features

Drug Class	Examples	Mechanism	Hypoglycemia Risk	Cardiovascular Benefit	Key Safety Concerns
Sulfonylureas	Glimepiride, Gliclazide, Glibenclamide	Insulin secretion (pancreatic β-cells)	High	Neutral	Hypoglycemia, weight gain
Biguanides	Metformin	↓ hepatic gluconeogenesis	Very low	Beneficial	GI upset, lactic acidosis (rare)
DPP-4 inhibitors	Sitagliptin, Vildagliptin	↑ incretin effect	Low	Neutral	Generally well tolerated
GLP-1 receptor agonists	Liraglutide, Semaglutide	↑ insulin, ↓ glucagon	Low	Cardioprotective	GI side effects, weight loss
SGLT2 inhibitors	Empagliflozin, Dapagliflozin	↑ urinary glucose excretion	Low	Cardiorenal benefit	UTI, dehydration, euglycemic ketoacidosis
Insulin	Basal/bolus regimens	Direct insulin replacement	Very high	Neutral	Hypoglycemia, weight gain

Key Clinical Observations

Sulfonylureas remain effective and inexpensive but have a narrow therapeutic drug.
Compared to newer agents (SGLT2 inhibitors and GLP-1 receptor agonists), sulfonylureas:
- - Lack proven cardiovascular protection
  - Carry significantly higher hypoglycemia risk
Elderly patients are particularly vulnerable due to:
- - Reduced renal clearance
  - Irregular dietary intake
  - Altered counter-regulatory responses

Recommendations

Reduce or discontinue sulfonylurea
Consider safer alternatives (low hypoglycemia risk agents)
Individualize HbA1c target
Monitor renal function and glucose trends

Patient Counseling

The patient and caregiver were educated regarding:

Recognition of hypoglycemia symptoms (sweating, tremors, dizziness, confusion)

Immediate management using fast-acting carbohydrates and keeping readily available glucose sources (sugar/juice/glucose tablets)

Importance of regular meals and medication timing
Home blood glucose monitoring
Need for prompt reporting of recurrent hypoglycemia

Discussion

The patient was on multiple hypoglycemics including Metformin and escalating dose of Glimepride. Although initial glycemic control was suboptimal, further dose increase led to a rapid drop in blood glucose. Sulfonylurea-induced hypoglycemia is a well-documented adverse drug reaction, particularly in elderly patients with cardiovascular disease. Glimepiride, although considered safer than older sulfonylureas, still carries significant risk when doses are escalated or when physiological reserves are reduced. This case emphasizes the importance of individualized glycemic targets, deprescribing strategies, preferring newer and safer alternatives and clinical pharmacy involvement in chronic disease management.

Conclusion

This case demonstrates a preventable episode of severe hypoglycemia induced by multiple hypoglycemics in an elderly patient with complex cardiovascular disease. Clinical pharmacy-led medication review and patient counseling are critical to improving medication safety and preventing recurrence.

References

American Diabetes Association. Standards of Care in Diabetes—2025. Diabetes Care. 2025;48(Suppl 1):S1–S350.
Inzucchi SE, et al. Management of hyperglycemia in type 2 diabetes. Diabetes Care. 2015;38(1):140–149.
Holstein A, Plaschke A. Risk factors for severe hypoglycemia in sulfonylurea-treated patients. Diabetes Metab Res Rev. 2003;19(6):491–500.
American Geriatrics Society. Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023.
Cryer PE. Hypoglycemia in diabetes: pathophysiology, prevalence, and prevention. Endocrinol Metab Clin North Am. 2010;39(4):641–654.
Bailey CJ, Day C. Metformin: pharmacology and clinical use. Diabetologia. 2004;47(7):1069–1077.
Riddle MC. Sulfonylureas and hypoglycemia risk in elderly patients. Clin Diabetes. 2017;35(1):10–16.

Preventing the preventable: Clinical pharmacy role in managing severe hypoglycemia in an elderly patient on glimepride

Preventing the preventable: Clinical pharmacy role in managing severe hypoglycemia in an elderly patient on glimepride

Shirlin M.S1*, Vignesh R1, Johnson2

Nightingale Journals

Shirlin M.S^1*, Vignesh R¹, Johnson²