Recurrent hypoglycaemia in an older patient with renal impairment

Patient A-104, an 82-year-old woman, is brought to the emergency department by her daughter. She is confused and drowsy. Her daughter reports that she has had a poor appetite and has eaten very little over the past week. She has a history of type 2 diabetes, hypertension and stage 3b chronic kidney disease. Her regular medications are gliclazide 160 mg once daily, ramipril 5 mg once daily and amlodipine 5 mg once daily. She has no known drug allergies. Her weight is 62 kg. On examination, she is lethargic, responding to voice only, with a normal blood pressure and pulse. Capillary blood glucose is 2.1 mmol/L. Blood tests taken on arrival show serum creatinine 1.6 mg/dL (eGFR 35 mL/min/1.73 m2) and HbA1c 52 mmol/mol (7.0%). She has had two similar hypoglycaemic episodes in the past month. She lives alone and her daughter supervises her medication. The emergency department clinician asks you to write the prescription for the immediate management of this episode, and to provide a revised prescription for her diabetes medication to take home.