What oral medication options are available for a patient with hyperglycemia who is already on alogliptin (dipeptidyl peptidase-4 inhibitor) 25 mg once daily and Jardiance (empagliflozin) 10 mg once daily?

From the Guidelines

The patient should be started on metformin, beginning with 500 mg twice daily and titrating up to 1000 mg twice daily as tolerated, due to its high glucose-lowering efficacy, low risk of hypoglycemia, and potential cardiovascular benefits, as supported by the most recent guidelines 1. Metformin is the first-line oral medication for type 2 diabetes and can be safely added to the patient's current regimen of alogliptin (a DPP-4 inhibitor) and Jardiance (an SGLT2 inhibitor). Some key points to consider when starting metformin include:

• Checking renal function to ensure the patient's eGFR is greater than 30 mL/min/1.73m², as metformin is contraindicated with eGFR <30 mL/min/1.73 m2 1
• Counseling the patient about potential gastrointestinal side effects, which are usually temporary, and advising them to take the medication with food to minimize these effects 1
• Monitoring for vitamin B12 deficiency, as metformin may cause a potential deficiency, and repleting as appropriate 1 If metformin is contraindicated or not tolerated, alternative options may include:
• Sulfonylureas, such as glimepiride, which have a high glucose-lowering efficacy but carry a risk of hypoglycemia and weight gain 1
• GLP-1 receptor agonists, which have a high to very high glucose-lowering efficacy and may provide cardiovascular benefits, but may have gastrointestinal side effects and require subcutaneous administration 1
• Pioglitazone, which has a high glucose-lowering efficacy but may increase the risk of heart failure and fluid retention, and is generally not recommended in kidney impairment due to potential for fluid retention 1

From the FDA Drug Label

Add-On Combination Therapy with Metformin A total of 637 patients with type 2 diabetes mellitus participated in a double-blind, placebo-controlled trial to evaluate the efficacy of JARDIANCE in combination with metformin Initial Combination Therapy with Metformin A total of 1,364 patients with type 2 diabetes mellitus participated in a double-blind, randomized, active-controlled trial to evaluate the efficacy of JARDIANCE in combination with metformin as initial therapy compared to the corresponding individual components

The patient is already on alogliptin and Jardiance (empagliflozin). Metformin can be considered as an add-on oral medication option for this patient, as the label discusses the efficacy of JARDIANCE in combination with metformin. Additionally, sulfonylurea can also be considered in combination with metformin, as mentioned in the label. However, the decision to add any new medication should be made with caution and under the guidance of a healthcare professional, considering the patient's individual needs and medical history 2.

• Key considerations:
  • Efficacy of JARDIANCE in combination with metformin
  • Potential addition of sulfonylurea to the treatment regimen
  • Individual patient needs and medical history
  • Consultation with a healthcare professional is necessary before making any changes to the treatment plan.

From the Research

Oral Medication Options for Hyperglycemia

The patient is already on alogliptin (dipeptidyl peptidase-4 inhibitor) 25 mg once daily and Jardiance (empagliflozin) 10 mg once daily. Considering the current medications, the following oral medication options can be considered:

• Metformin: Although its use in hospitalized patients is controversial, metformin can be used safely in many patients with normal kidney function 3.
• Sulfonylureas: However, these should be withheld to avoid hypoglycemia in patients with limited caloric intake 4.
• Thiazolidinediones: These should be temporarily stopped in patients with cardiovascular conditions to avoid precipitating heart failure 4.

Considerations for Glycemic Control

When managing hyperglycemia, the following considerations should be taken into account:

• Blood glucose targets: The current target is 140 to 180 mg per dL 4, 3.
• Insulin regimens: Basal insulin combined with short-acting insulin before meals can be used to achieve glycemic control 4.
• Patient characteristics: Individual patient characteristics, such as diabetic status and prehospital glucose control, should be considered when determining glycemic targets 5, 6.

Additional Considerations

Other factors to consider when managing hyperglycemia include:

• Patient education: Comprehensive care plans involving adequate patient education can help minimize barriers to optimizing glycemic control 7.
• Treatment side effects: Newer therapies and devices can help minimize treatment side effects and improve treatment outcomes 7.