What is the diagnosis and recommended management for a 60-year-old female patient with diabetes mellitus, presenting with a recurring gluteal mass that occasionally bleeds and leaks clear fluid, and experiencing hyperglycemia while transitioning from Byetta (exenatide) to Ozempic (semaglutide)?

From the Guidelines

The patient can be transitioned to the 0.5 mg dose of Ozempic (semaglutide) since she has tolerated the starter dose well and her blood glucose levels are increasing (238,312 mg/dL). This dose escalation follows the standard titration protocol for Ozempic, which typically starts at 0.25 mg weekly for 4 weeks before increasing to 0.5 mg weekly. Given her history of diabetes mellitus and current elevated glucose readings, increasing to the 0.5 mg dose is appropriate to improve glycemic control, as GLP-1 receptor agonists like Ozempic have high glucose-lowering efficacy, with minimal risk for hypoglycemia 1.

The patient should continue weekly injections on the same day each week, and can administer the medication in the abdomen, thigh, or upper arm. She should monitor for potential side effects such as nausea, vomiting, diarrhea, or abdominal pain, which typically improve over time. Additionally, the patient should continue regular blood glucose monitoring and report any severe hypoglycemia or persistent gastrointestinal symptoms.

Key considerations in this decision include:

• The patient's current glucose levels, which are above target
• The patient's tolerance of the starter dose of Ozempic
• The standard titration protocol for Ozempic
• The glucose-lowering efficacy and safety profile of GLP-1 receptor agonists, as outlined in the 2018 consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) 1.

It is also important to consider the patient's overall clinical context, including her past medical history and current medications, to ensure that the dose increase is appropriate and safe. The American Diabetes Association standards of medical care in diabetes, as outlined in the 2016 synopsis, also support the use of GLP-1 receptor agonists like Ozempic in patients with type 2 diabetes who require additional glucose-lowering therapy 1.

From the FDA Drug Label

Your dose of OZEMPIC and other diabetes medicines may need to change because of: • change in level of physical activity or exercise, weight gain or loss, increased stress, illness, change in diet, fever, trauma, infection, surgery or because of other medicines you take.

The patient's dose of OZEMPIC may be increased to 0.5mg if tolerated and if their sugar levels are increasing 2. However, the decision to increase the dose should be made by the healthcare provider, taking into account the patient's individual needs and medical history. Key factors to consider include:

• The patient's ability to tolerate the current dose of OZEMPIC
• The patient's increasing sugar levels
• The presence of any adverse effects or interactions with other medications It is essential to consult with the healthcare provider to determine the best course of action for the patient's diabetes management.

From the Research

Patient's Current Condition

The patient is a 60-year-old female with a past medical history of diabetes mellitus, urinary incontinence, headaches, hemorrhoids, hypertension, edema, IBS, and hyperlipidemia. She presents with a complaint of a bump in the gluteal area that has been bleeding and leaking clear liquid, which has occurred 1-2 times every year. Her current glucose levels are high, with readings of 238 and 312.

Medication History

The patient was previously on the maximum dose of Byetta and has been transitioned to Ozempic, starting at the starter dose. She is now tolerating Ozempic and is requesting an increase in dose to 0.5 mg due to increasing sugar levels.

GLP-1 Receptor Agonists

• GLP-1 receptor agonists, such as semaglutide, have been shown to be effective in reducing HbA1c levels and promoting weight loss in patients with type 2 diabetes 3, 4, 5.
• These medications have also been found to have a low risk of hypoglycemia and can be used in combination with other glucose-lowering agents or insulin 3, 6.
• Semaglutide, in particular, has been shown to have a half-life of 7 days and can be administered once weekly, with a potential role in patients who require weight loss with a low risk of hypoglycemia 4.

Dose Titration

• The patient is currently on the starter dose of Ozempic and is requesting an increase in dose to 0.5 mg.
• Studies have shown that semaglutide 2.0 mg is superior to 1.0 mg in reducing HbA1c levels, with additional body weight loss and a similar safety profile 5.
• However, it is essential to consider the patient's individual response to the medication and potential side effects before increasing the dose.

Safety and Efficacy

• GLP-1 receptor agonists, including semaglutide, have been found to have a favorable safety profile, with gastrointestinal side effects being the most commonly reported adverse events 7, 5, 6.
• The patient's current glucose levels and medication history should be taken into account when considering the safety and efficacy of increasing the dose of Ozempic.