Rising Hba1c Who Stopped Metformin Because of Stomach Upset — Free SCA Practice Case
Man with rising HbA1c who stopped metformin because of stomach upset
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Materials for Candidate
Please review before starting the consultation
Full Name
Keith Warren
Age
62 years
Consultation Type
TelephoneAge
62
Situation
Telephone Consultation. Booked to discuss recent diabetes bloods.
Reason for Encounter
"I've had a message that my diabetes blood test has gone up. To be honest, I stopped the metformin months ago because it wrecked my stomach."
Medical Records
- ●PMH: Type 2 diabetes (5 years). Overweight (BMI 32). Hypertension.
- ●Medications: Metformin 1 g BD (standard-release) — poor adherence / largely stopped. Ramipril 5 mg OD.
- ●Allergies: NKDA.
- ●Recent results: HbA1c 74 mmol/mol (rising from 58 six months ago). eGFR normal. BP 138/84.
Patient Script
For the friend playing the patient role
Character Overview: You are Keith, a 62-year-old delivery driver with type 2 diabetes. You stopped taking your metformin a few months ago because it caused you diarrhoea and stomach cramps, and no one offered an alternative. You know your latest blood test has gone up. You are pragmatic but a bit fatalistic about your diabetes, and your diet is poor (long hours, fast food on the road). You are willing to engage if given practical, realistic options rather than being lectured.
Opening Sentence: "Hello Doctor. I got a text saying my diabetes number's gone up. I'll be straight with you — I stopped the metformin a few months back. It gave me terrible guts, diarrhoea and cramps, and I just couldn't carry on with it. Nobody told me what else to do."
History if Asked (Data Gathering Phase)
- ●The metformin intolerance: "Awful diarrhoea and stomach cramps whenever I took it. I put up with it for a while, then just stopped. It was affecting my work — I can't be stopping the van every ten minutes."
- ●Current medication: "So I'm really only taking my blood pressure tablet now. I stopped the metformin."
- ●Diet: "Rubbish, if I'm honest. I'm on the road all day — garage sandwiches, fast food, energy drinks. No time to eat properly."
- ●Symptoms: "I feel alright, maybe a bit more tired and thirsty lately. No other problems."
- ●Understanding: "I know the number going up isn't good, but I didn't know there were other tablets I could try."
ICE — Ideas, Concerns, Expectations
The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.
- ●Ideas: Keith assumed that because metformin disagreed with him, his only option was to stop it, and he is somewhat resigned to his diabetes being "bad." "I figured if the tablets don't agree with me, that's that. I've sort of accepted my diabetes is bad."
- ●Concerns: He is worried, in a background way, about the long-term complications of diabetes, and about how he manages medication and diet with the realities of his job. "I do worry about where this leads — my dad lost a toe to his diabetes. But I don't know how to manage it with my job."
- ●Expectations: He wants a practical, workable plan — ideally a tablet that does not wreck his stomach — not a lecture. "I want something that actually works for me, and realistic advice, not just being told to eat better."
If Asked — Medical History and Lifestyle
The patient confirms these details only when directly asked.
- ●Diabetes history: "Diagnosed about five years ago. Was on metformin, controlled-ish, until I stopped it."
- ●Other medications tried: "Only ever the metformin and the blood-pressure tablet."
- ●Hypos / other agents: "No, I've never been on anything that caused lows."
- ●Complications/foot/eyes: "I get my eye and foot checks. No problems flagged so far."
- ●Alcohol/smoking: "A few beers at the weekend, non-smoker."
- ●Weight: "I know I'm overweight. The job doesn't help — sitting driving all day."
Responses to Management (The Negotiation Phase)
- ●If the Doctor suggests trying modified-release metformin: "There's a version that's easier on the stomach? Why was I not offered that instead of just stopping?" (The tested point is offering modified-release metformin for GI intolerance before abandoning it.)
- ●If the Doctor discusses escalation/alternative agents: "And if that still doesn't work, what else is there? Something that might even help the weight?" (The tested point is knowing the escalation options and their relative merits, including weight and cardiovascular considerations.)
- ●If the Doctor negotiates diet realistically: "I'm on the road all day — 'eat healthily' is easier said than done. What can I actually do?" (The tested point is practical, realistic dietary negotiation tailored to his job.)
- ●If the Doctor explains why the rising HbA1c matters: "So how bad is 74? What does it mean for me long-term?"
- ●If the Doctor arranges follow-up/monitoring: "When would you check the number again?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Find Out Why Control Has Worsened
- ●A rising HbA1c should prompt asking why — commonly non-adherence (as here, due to intolerance), rather than assuming genuine treatment failure. Correcting the cause is more effective than blindly escalating.
Managing Metformin Intolerance
- ●Gastrointestinal intolerance is the commonest reason metformin is stopped. Before abandoning it, try modified-release (MR) metformin (often better tolerated), titrate slowly, and take it with food. Metformin remains first-line and has good evidence.
Escalation Options in Type 2 Diabetes (NICE NG28)
- ●Add-on/second-line options include SGLT2 inhibitors, DPP-4 inhibitors, GLP-1 receptor agonists, sulfonylureas, and pioglitazone.
- ●Choose according to cardiovascular/renal risk (SGLT2 inhibitors have strong CV/renal benefit), weight (SGLT2 inhibitors and GLP-1 agonists aid weight loss), hypoglycaemia risk (sulfonylureas cause hypos), and renal function.
- ●In people with, or at high risk of, cardiovascular or renal disease, an SGLT2 inhibitor is often favoured.
Individualised HbA1c Targets
- ●Agree an individualised HbA1c target (tighter for younger/fitter patients on non-hypo-causing drugs; more relaxed where hypoglycaemia risk or frailty). An HbA1c of 74 mmol/mol indicates poor control needing action.
Realistic Lifestyle Negotiation
- ●Tailor dietary and lifestyle advice to the person's real circumstances (here, a delivery driver) — achievable swaps and planning beat unrealistic instructions. Offer structured education, dietitian, and weight-management support.
Whole-Person Cardiovascular Risk
- ●Manage the whole cardiovascular-risk picture — blood pressure, lipids/statins, smoking, and weight — not just glucose.
Monitoring and Complication Surveillance
- ●Arrange repeat HbA1c (~3 months) and ensure retinal screening, foot checks, renal (ACR), and cardiovascular-risk review are current.
Common Candidate Mistakes in This Case
- ●Not addressing the intolerance: escalating or accepting stopped metformin without trying modified-release.
- ●Irrational drug escalation: choosing an add-on without considering weight, cardiovascular/renal risk, hypoglycaemia, and renal function.
- ●Lecturing about diet: giving unrealistic/generic advice that ignores his job and disengages him.
- ●Focusing only on glucose: neglecting blood pressure, lipids, and overall cardiovascular risk.
- ●No monitoring or shared plan: failing to arrange repeat HbA1c, complication surveillance, and an agreed, realistic plan.