From the Guidelines
I strongly recommend intensifying the current diabetes management approach for this 76-year-old diabetic patient, as the A1C has risen from 6.3 to 7.0 despite being on metformin 2000mg daily. For this patient, consider adding a second medication such as a DPP-4 inhibitor (like sitagliptin 100mg daily) or an SGLT-2 inhibitor (like empagliflozin 10mg daily) to the existing metformin regimen, as suggested by the most recent guidelines 1. Before adding medication, ensure the patient is adhering to the current metformin dose, taking it with meals to minimize gastrointestinal side effects. Also, review and optimize lifestyle factors including:
- Diet
- Physical activity appropriate for age
- Stress management The target A1C for older adults with diabetes typically ranges from 7.0-8.0% depending on overall health status and comorbidities, so while the current 7.0% may be acceptable, the upward trend is concerning, as indicated by recent studies 1. The rising A1C indicates worsening glucose control, likely due to progressive beta cell dysfunction which is common in type 2 diabetes, necessitating treatment intensification to prevent complications like cardiovascular disease, neuropathy, and nephropathy. According to the American Diabetes Association standards of care in diabetes-2025, when A1C is ≥1.5% above the individualized glycemic goal, many individuals will require dual-combination therapy or a more potent glucose-lowering agent to achieve and maintain their goal A1C level 1. Therefore, adding a second medication to the existing metformin regimen is a reasonable next step in managing this patient's diabetes, considering the patient's age, current A1C level, and the need to prevent diabetes-related complications, as supported by recent evidence 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient's Current Condition
- The patient is a 76-year-old male with diabetes, currently taking 2000 mg of metformin.
- His A1C level was initially 6.3, but it has increased to 7.0.
Relevant Studies
- A study published in 2013 2 compared the effects of sitagliptin and glimepiride on glucose variability in patients with type 2 diabetes who were already taking metformin. The results showed that both sitagliptin and glimepiride reduced HbA1c levels, but sitagliptin was more effective in reducing glucose variability.
- Another study published in 2019 3 discussed the use of glycated hemoglobin A1c to assess chronic glycemic control in intensive care unit patients. The study suggested that patients with elevated glycated hemoglobin A1c may be able to tolerate hyperglycemia and large glucose fluctuations better, but they are also at a higher risk of hypoglycemia.
- A systematic review and meta-analysis published in 2018 4 compared the efficacy and safety of sodium-glucose cotransporter 2 inhibitors (SGLT2i) plus dipeptidyl peptidase-4 inhibitors (DPP4i) with placebo plus DPP4i in patients with type 2 diabetes. The results showed that SGLT2i/DPP4i achieved better glycemic control and greater weight reduction without increasing the risk of hypoglycemia and urinary tract infection.
- A study published in 2025 5 compared the cardiovascular and mortality outcomes of DPP-4 inhibitors versus sulfonylureas as metformin add-on therapy in patients with type 2 diabetes. The results showed that DPP-4 inhibitors plus metformin were associated with a significantly lower risk of major adverse cardiovascular events and all-cause mortality compared to sulfonylureas plus metformin.
- A study published in 2019 6 examined the relationships between time in range, hyperglycemia metrics, and HbA1c in patients with type 1 diabetes. The results showed that CGM metrics were highly correlated with each other, but only moderately correlated with A1C.
Possible Next Steps
- Consider adjusting the patient's medication regimen to include a DPP-4 inhibitor or an SGLT2 inhibitor, as these have been shown to be effective in reducing HbA1c levels and improving glycemic control 2, 4, 5.
- Monitor the patient's glucose levels and adjust their medication regimen as needed to achieve optimal glycemic control 3, 6.