Prescription Review practice question: a 74-year-old with recurrent hypoglycaemia in general practice

2 marks for ticking the glimepiride and nothing else. Only one drug on this chart makes insulin: glimepiride, a sulfonylurea that stimulates secretion regardless of the prevailing glucose, which is why its SmPC (Brown & Burk, revised December 2020) builds its central warnings around hypoglycaemia. The chart tells the story in numbers: the dose was doubled to 4 mg two months ago, the HbA1c has fallen from 58 to 44 mmol/mol — well through the target of 53 — and two mid-morning collapses at a capillary glucose of 2.6 mmol/L have followed the morning dose. That is over-treatment in a 74-year-old, in whom the honest correction is a dose reduction, not just a snack. Do not tick the metformin: its own SmPC closes it in one sentence — 'It does not stimulate insulin secretion and therefore does not cause hypoglycaemia.' The remaining rows have no glycaemic pharmacology at all, and the printed eGFR of 79 removes renal accumulation as a competing mechanism. The rule that transfers: when a diabetic chart produces a low glucose, find the secretagogue (or the insulin) first, and ask what changed and when.

2 marks for ticking the propranolol and nothing else. The clue is what is missing: on neither occasion did he feel palpitations, tremor or hunger before the collapse. Those early warnings are adrenergic — driven by the catecholamine surge of counter-regulation — and a non-selective beta-blocker sits directly on top of them. Propranolol's SmPC (Amarox, revised April 2026) says so twice: it 'may block/modify the signs and symptoms of the hypoglycaemia (especially tachycardia)' and it 'modifies the tachycardia of hypoglycaemia', with the explicit instruction that 'Caution must be exercised in the concurrent use of propranolol and hypoglycaemic therapy in diabetic patients.' The glimepiride SmPC states the same interaction from the other side: under beta-blockers 'the signs of adrenergic counter regulation to hypoglycaemia may be reduced or absent.' Restarted 6 weeks ago for migraine, propranolol is the only sympatholytic row on the chart — nothing else has adrenergic pharmacology to lose. The practical lesson: in a patient on a sulfonylurea or insulin who needs a beta-blocker, a cardioselective agent is the safer habit, and any beta-blocker demands a warning that hypoglycaemia may now announce itself only as sweating or confusion.