From the Guidelines
The patient should continue taking Synjardy 12.5/1000 mg twice daily and Januvia 100 mg daily, while restarting Lantus insulin at 30-35 units daily as previously prescribed. Their recent HbA1c of 11.1 indicates poorly controlled diabetes, with blood sugars spiking to the 300s after meals, as noted in the patient's history 1. To improve control, the patient should track foods causing blood sugar spikes and limit them, eat smaller consistent meals throughout the day, reduce carbohydrates, fats, and sugary foods/drinks, and increase consumption of vegetables and lean meats. Regular exercise and weight loss are also recommended, as emphasized in the 2017 American Diabetes Association standards of medical care in diabetes 1. The patient should continue using their Libre glucose monitor and ensure they complete annual diabetic eye and foot exams. Medication adherence, particularly with insulin, is crucial for managing their diabetes, as their current elevated HbA1c puts them at risk for complications. The combination of oral medications (Synjardy, which contains empagliflozin and metformin, plus Januvia) along with basal insulin therapy provides a comprehensive approach to control both fasting and post-meal glucose levels, in line with recommendations for pharmacologic therapy for type 2 diabetes 1.
Key aspects of the patient's management plan include:
- Continuing current oral medications (Synjardy and Januvia) to control blood glucose levels
- Restarting Lantus insulin at 30-35 units daily to improve glycemic control
- Tracking and limiting foods that cause blood sugar spikes
- Eating smaller, consistent meals throughout the day
- Increasing consumption of vegetables and lean meats
- Regular exercise and weight loss
- Continuing use of the Libre glucose monitor
- Completing annual diabetic eye and foot exams
By following this management plan, the patient can improve their glycemic control, reduce the risk of complications, and enhance their overall quality of life, as supported by the latest guidelines and evidence-based practices in diabetes management 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient's Current Condition
- The patient's last HbA1c level was 11.1, indicating poor glycemic control.
- The patient is nonadherent with insulin, which may be contributing to the high HbA1c level.
- The patient's blood sugars spike up to the 300's after eating, suggesting postprandial hyperglycemia.
Medication Regimen
- The patient is currently taking Synjardy 12.5 to 1000 mg PO BID daily and Januvia 100 mg daily.
- The patient was advised to restart Lantus 30-35 units daily, as per the last pharmacy note.
- Studies have shown that the addition of glargine to metformin-sitagliptin therapy can improve glycemic control in patients with type 2 diabetes 2.
- The use of empagliflozin, a sodium-glucose cotransporter-2 inhibitor, has been shown to improve glycemic control and reduce body weight and systolic blood pressure in patients with type 2 diabetes 3, 4.
Lifestyle Changes
- The patient was advised to work on lifestyle changes, including diet, regular exercise, and weight loss.
- Eating consistent smaller meals throughout the day, avoiding carbohydrates, fats, and sugary drinks/foods, and eating more vegetables and lean meat may help improve glycemic control.
- Studies have shown that initial triple combination therapy with metformin, sitagliptin, and empagliflozin can lead to achievement of the glycemic target goal and improvement in metabolic function and albuminuria 5.
- A short-term intensive intervention with insulin glargine, sitagliptin, and metformin, along with lifestyle approaches, may also help achieve remission of type 2 diabetes 6.
Monitoring and Follow-up
- The patient has a free libre to check her blood sugars, which has made it easier for her to monitor her glucose levels.
- The patient was reminded to undergo annual diabetic eye and foot exams to monitor for complications.
- Regular follow-up appointments with the healthcare provider will be necessary to monitor the patient's progress and adjust the treatment plan as needed.