From the Guidelines
I would recommend increasing the Jardiance (empagliflozin) dose from 10mg to 25mg daily as your first adjustment. According to the evidence from 1, Jardiance has a higher dose available (25mg), and increasing it can provide further benefits in reducing blood glucose levels, cardiovascular protection, and weight loss. Additionally, SGLT2 inhibitors like Jardiance work through a different mechanism than GLP-1 receptor agonists like Trulicity, so optimizing the Jardiance dose before considering other medication changes makes physiological sense.
Key Considerations
- The patient is already at the maximum dose of Trulicity (dulaglutide) 1.5mg weekly, as indicated in the table from 1, which shows the recommended doses for CV benefit.
- Increasing Jardiance may require monitoring for side effects such as genital yeast infections, urinary tract infections, and volume depletion, as mentioned in 1.
- It is essential to consider the patient's kidney function before increasing the Jardiance dose, as it is not recommended for patients with eGFR <45 mL/min/1.73 m², according to 1.
Potential Benefits and Risks
- Increasing Jardiance can provide further glucose reduction benefits, as stated in 1, which can improve the patient's glycemic control and reduce the risk of cardiovascular events.
- However, it is crucial to weigh the potential benefits against the risks, such as increased risk of genital fungal infections, urinary tract infections, and euglycemic diabetic ketoacidosis, as mentioned in 1.
From the FDA Drug Label
2.1 Adult Dosage The recommended starting dosage of TRULICITY is 0.75 mg injected subcutaneously once weekly. Increase the dosage to 1.5 mg once weekly for additional glycemic control. If additional glycemic control is needed, increase the dosage in 1.5 mg increments after at least 4 weeks on the current dosage.
The patient is already taking 1.5 mg of Trulicity, so if additional glycemic control is needed, the dosage of Trulicity can be increased in 1.5 mg increments after at least 4 weeks on the current dosage.
The patient is currently taking Jardiance 10mg and Trulicity 1.5mg.
- The Trulicity dose can be increased to 3mg after at least 4 weeks on the current dosage if additional glycemic control is needed, as per the dosage recommendations 2.
- There is no information provided about adjusting the dose of Jardiance. Therefore, based on the provided information, Trulicity should be increased first.
From the Research
Treatment Options for Type 2 Diabetes
The patient is currently taking Jardiance (empagliflozin) 10mg and Trulicity (dulaglutide) 1.5mg for type 2 diabetes. To determine which medication to increase first, let's examine the properties and effects of each:
- Jardiance (empagliflozin): A sodium glucose cotransporter-2 (SGLT2) inhibitor that provides a novel insulin-independent mechanism of lowering blood glucose 3, 4, 5.
- Trulicity (dulaglutide): A glucagon-like peptide-1 (GLP-1) receptor agonist that stimulates insulin secretion, blunts glucagon secretion, increases satiety, and decreases the rate of gastric emptying 6, 7.
Considerations for Increasing Medication
When considering which medication to increase first, the following points should be taken into account:
- Efficacy: Both medications have been shown to be effective in improving glycemic control, but GLP-1 receptor agonists like dulaglutide may have a more profound effect on overnight and fasting plasma glucose and HbA1c 6.
- Cardiovascular benefits: Empagliflozin has been shown to have cardioprotective properties, particularly in patients with established cardiovascular disease 3, 4.
- Side effects: Both medications have their own set of potential side effects, including gastrointestinal symptoms for dulaglutide and genital infections, kidney failure, and diabetic ketoacidosis for empagliflozin 3, 4.
Decision
Based on the available evidence, it is recommended to increase the dose of Trulicity (dulaglutide) first, as it has been shown to have a more profound effect on glycemic control and may be more effective in reducing HbA1c levels 6, 7. However, the decision to increase the dose of either medication should be made under the guidance of a healthcare professional, taking into account the individual patient's needs and medical history.