What interventions are recommended for a patient with severely uncontrolled diabetes (Diabetes Mellitus) and a Hemoglobin A1c (HbA1c) level greater than 15%, comorbid schizophrenia that is well-controlled with antipsychotics, who refuses injectable medication for diabetes, is noncompliant with oral hypoglycemic agents, has low health literacy, and lacks insight into the risks of uncontrolled diabetes?

From the Guidelines

For a patient with severely uncontrolled diabetes (A1C >15%), comorbid well-controlled schizophrenia, medication refusal, and low health literacy, I recommend a multifaceted approach focusing on simplified oral medication regimens, behavioral interventions, and coordinated care. Start with once-daily oral medications like extended-release metformin (500-1000mg daily, gradually increasing to 2000mg as tolerated) combined with an SGLT-2 inhibitor such as empagliflozin (10-25mg daily) 1. Consider adding a GLP-1 receptor agonist in oral form like semaglutide (Rybelsus) starting at 3mg daily, then increasing to 7mg or 14mg as tolerated. Implement directly observed therapy during regular mental health appointments, using pill boxes and medication reminders. Engage family members or caregivers in medication supervision and establish a coordinated care team including primary care, endocrinology, psychiatry, and social work. Use simple visual aids and concrete examples to explain diabetes complications in terms the patient can understand. Maintain antipsychotic medication stability while considering metabolically favorable options like aripiprazole or lurasidone if changes become necessary, as suggested by recent guidelines 1. This approach addresses medication adherence barriers while respecting the patient's refusal of injectable treatments and maintaining psychiatric stability, which is crucial as poor schizophrenia control could further worsen diabetes management. Key considerations include:

• Simplified medication regimens to improve adherence
• Behavioral interventions to address low health literacy and lack of insight into diabetes risks
• Coordinated care to ensure comprehensive management of diabetes and schizophrenia
• Regular monitoring and adjustment of treatment plans as needed, taking into account the latest recommendations for diabetes management 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Profile

• Patient has severely uncontrolled diabetes with A1c >15%
• Patient has co-morbid schizophrenia that is well controlled with antipsychotics
• Patient refuses injectable medication for diabetes
• Patient is noncompliant with oral medication
• Patient has low health literacy and lack of insight into risks of uncontrolled diabetes

Treatment Considerations

• According to 2, patients with severely uncontrolled diabetes mellitus require continuous clinical attention and laboratory monitoring
• Administration of insulin, rehydration with NaCl solutions, and IV administration of K+ are essential features of treatment for diabetic ketoacidosis and nonketotic hyperglycemia
• 3 suggests that intensifying the diabetes medication regimen at discharge can reduce the risk of hospital readmission and emergency department use in patients with severely uncontrolled type 2 diabetes mellitus

Medication Options

• 4 discusses the use of SGLT2 inhibitors and metformin as dual antihyperglycemic therapy, which may be effective in improving glycemic control with a low risk of hypoglycemia
• However, the combination of metformin and SGLT2 inhibitors may increase the risk of metabolic acidosis
• 5 compares the effectiveness of SGLT2 inhibitors and sulfonylureas in patients with type 2 diabetes, finding that SGLT2 inhibitors are associated with a reduced risk of all-cause mortality
• 6 evaluates the comparative effectiveness of SGLT2 inhibitors, GLP-1 receptor agonists, DPP-4 inhibitors, and sulfonylureas on the risk of major adverse cardiovascular events, finding that SGLT2 inhibitors and GLP-1 receptor agonists are associated with a lower risk of MACE compared to DPP-4 inhibitors and sulfonylureas

Potential Interventions

• Educating the patient on the importance of glycemic control and the risks of uncontrolled diabetes
• Exploring alternative medication options that the patient may be more willing to take, such as oral medications
• Providing ongoing support and monitoring to help the patient manage their diabetes and schizophrenia
• Considering the use of SGLT2 inhibitors or GLP-1 receptor agonists as part of the patient's treatment plan, given their potential benefits in reducing the risk of MACE and improving glycemic control 5, 6