What is the next pharmacologic intervention for a patient with a stable Hemoglobin A1C (HbA1C) level of 7.2% and no adverse effects from metformin (Metformin) 500 milligrams twice daily?

From the Guidelines

No adjustments are necessary as EC's A1C is stable at 7.2%. This represents good glycemic control for most patients with diabetes, as the typical target A1C is <7.5% for many patients, particularly those who are not newly diagnosed [ 1 ]. EC has shown positive progress with the current metformin regimen (500 mg twice daily), demonstrated by the reduction in A1C from baseline and the 3-pound weight loss without experiencing any adverse effects.

According to the standards of medical care in diabetes-2020 [ 1 ], metformin is the preferred initial pharmacologic agent for the treatment of type 2 diabetes. The current regimen is effective, and adding additional medications like insulin glargine or liraglutide, or increasing the metformin dose, would be premature at this point. These changes would typically be considered if the A1C remained significantly above target despite the current therapy.

Some key points to consider in this decision include:

• The patient's A1C is at a stable level, indicating good glycemic control
• The patient has not experienced any adverse effects from the current metformin regimen
• The patient has shown positive progress with the current regimen, including a reduction in A1C and weight loss
• The standards of medical care in diabetes-2020 recommend metformin as the preferred initial pharmacologic agent for the treatment of type 2 diabetes [ 1 ]

Continuing the present regimen while reinforcing lifestyle modifications (diet and exercise) would be appropriate, with another follow-up visit in 3-6 months to reassess glycemic control. This approach prioritizes the patient's morbidity, mortality, and quality of life, and is consistent with the recommendations of the standards of medical care in diabetes-2020 [ 1 ].

From the FDA Drug Label

The recommended starting dose of metformin hydrochloride tablets are 500 mg orally twice a day or 850 mg once a day, given with meals. Increase the dose in increments of 500 mg weekly or 850 mg every 2 weeks on the basis of glycemic control and tolerability, up to a maximum dose of 2550 mg per day, given in divided doses.

The patient's A1C is 7.2%, which is close to the target range, and they have lost 3 pounds. No adjustments are necessary as her A1C is stable, and the patient has not experienced any adverse effects from taking 500 mg metformin twice daily. 2

From the Research

Pharmacologic Intervention

The patient's A1C level is 7.2%, which is close to the target level of <7.0% as specified in current guidelines 3. Considering the patient has lost 3 pounds and has not experienced any adverse effects from taking 500 mg metformin twice daily, the following options can be considered:

• No adjustments are necessary as her A1C is stable
• Increase the metformin dose
• Add liraglutide to their regimen
• Add insulin glargine to their regimen

Comparison of Treatment Options

Studies have compared the efficacy of liraglutide and insulin glargine in patients with type 2 diabetes. One study found that liraglutide may be an appropriate alternative to basal insulin in type 2 diabetes, including when baseline HbA1c is very high (≥9.0%) 4. Another study found that liraglutide is superior to insulin glargine in newly diagnosed type 2 diabetes patients with HbA1c > 9% in improving beta-cell function, insulin sensitivity, and glucose homeostasis 5. However, a different study found that insulin glargine had greater reductions in HbA1c and fasting plasma glucose compared to liraglutide, but also had a higher rate of symptomatic hypoglycaemia 6.

Considerations for Treatment

When deciding on the next pharmacologic intervention, the patient's current A1C level, weight loss, and lack of adverse effects should be taken into account. The patient's A1C level is already close to the target level, so adding a new medication may not be necessary. However, if the patient's A1C level is not at the target level, adding liraglutide or insulin glargine could be considered. The patient's weight loss and lack of adverse effects suggest that increasing the metformin dose could be a viable option. Key points to consider:

• The patient's A1C level is close to the target level
• The patient has lost weight and has not experienced any adverse effects
• Liraglutide and insulin glargine have been compared in several studies, with varying results
• Increasing the metformin dose could be a viable option
• The decision should be based on the patient's individual needs and response to treatment 3, 6