An Older Woman at A1c Goal with Asymptomatic Hypoglycemia: What Next?

RM, a 78-year-old woman, presents to the clinic to establish care. Her past medical history is significant for type 2 diabetes (T2DM), hypertension, and atrial fibrillation. Current medications are:

Metformin          500 mg/bid                       Lisinopril         10 mg/day
Pioglitazone         45 mg/day                      Atorvastatin      10 mg/day  
Glyburide             10 mg/day                      Rivaroxaban     20 mg/day   
Metoprolol          100 mg/day
 

She states that she is happy with her current medications as all are “affordable” given her limited income and that it took her a long time to get her diabetes under control. Laboratory values include: HbA1c, 6.6%; basic metabolic panel, WNL (SCr, 1.2; eGFR, 45 mL/min). Vitals signs are: weight, 70kg; blood pressure, 126/72 mm Hg; pulse, 64. RM lives alone and tries to exercise 3 times per week and watches her diet. She notes that at least twice a week she obtains fasting blood glucose (FBG) readings <70 mg/dL but denies feeling poorly.