What is the appropriate management for a 67-year-old patient with hyperglycemia, currently on insulin glargine (100 units twice daily), metformin (1000 mg twice daily), insulin aspart (100 units on a sliding scale), and dulaglutide (once weekly)?

From the Guidelines

The patient's diabetes management should be adjusted to address the elevated morning blood glucose of 244 mg/dL, with a focus on optimizing basal insulin coverage and mealtime glucose control, as recommended by the most recent guidelines 1.

Current Regimen Assessment

The patient is currently on glargine 100 units BID, metformin 1000 mg BID, insulin aspart 100 sliding scale, and dulaglutide once a week. Given the elevated fasting glucose, it suggests inadequate overnight insulin coverage despite the substantial current regimen.

Recommended Adjustments

• Increase the glargine dose by 2 units, as 50% of the fasting fingerstick glucose values are over the goal, according to the standards of care in diabetes-2024 1.
• Evaluate the effectiveness of the current sliding scale insulin aspart protocol and consider implementing a fixed pre-meal dose of insulin aspart (starting with 4-6 units before meals) alongside the sliding scale to better address mealtime glucose excursions.
• Continue metformin 1000 mg BID and weekly dulaglutide as prescribed.
• Monitor blood glucose more frequently (before meals and at bedtime) for 1-2 weeks after these adjustments and follow up within 2 weeks to reassess.

Rationale

These changes aim to address the dawn phenomenon (early morning rise in blood glucose due to counter-regulatory hormones) and provide better 24-hour glucose control. Given the patient's age (67), any insulin dose increases should be made cautiously to avoid hypoglycemia risk, particularly if they live alone or have hypoglycemia unawareness, as highlighted in the pharmacologic approaches to glycemic treatment standards of care in diabetes-2025 1.

Key Considerations

• The patient's regimen should be simplified and optimized based on the latest guidelines for older adults with diabetes 1, focusing on basal insulin titration and the potential addition of non-insulin agents if necessary.
• Regular monitoring and follow-up are crucial to adjust the treatment plan as needed and to minimize the risk of hypoglycemia and other complications, in line with the recommendations for pharmacologic approaches to glycemic treatment 1.

From the FDA Drug Label

Table 7: Results at Week 24 of TRULICITY Compared to Placebo as Add-On to Glimepiride in Adult Patients with Type 2 Diabetes Mellitusa ... 24-Week Primary Time Point Placebo TRULICITY1.5 mg ... Fasting Serum Glucose (mg/dL) (Mean) Baseline 175 178 Change from baselineb 2 -28 Difference from placebob (95% CI) -30 (-44, -15)††

The patient's current blood glucose level is 244mg/dL before a meal in the morning. The dulaglutide label shows that treatment with TRULICITY 1.5 mg once weekly resulted in a statistically significant reduction in HbA1c and fasting serum glucose compared to placebo.

• The mean change from baseline in fasting serum glucose for TRULICITY 1.5 mg was -28 mg/dL.
• However, the label does not provide information on the expected blood glucose level for a patient on dulaglutide with a specific dose of glargine and metformin.
• Given the patient's current blood glucose level and medication regimen, including glargine 100 unit BID, metfoemin 1000 mg BID, Insulin Aspart 100 sliding scale, and dulaglutide once a week, it is unclear if the current treatment is effective in achieving the desired blood glucose level.
• A conservative clinical decision would be to monitor the patient's blood glucose levels and adjust the treatment regimen as needed to achieve the desired level, considering the patient's individual response to the current medications 2.

From the Research

Patient's Current Treatment and Blood Glucose Level

• The patient is currently taking glargine 100 units BID, metformin 1000 mg BID, insulin aspart 100 sliding scale, and dulaglutide once a week.
• The patient's blood glucose level is 244mg before a meal in the morning.

Studies on Treatment Efficacy

• A study published in 2006 3 compared the efficacy and safety of add-on insulin glargine versus rosiglitazone in insulin-naive patients with type 2 diabetes inadequately controlled on dual oral therapy with sulfonylurea plus metformin.
• Another study published in 2019 4 investigated whether specific baseline glycaemic patterns respond differentially to dulaglutide compared to insulin glargine.
• A 2015 study 5 compared the efficacy and safety of once-weekly dulaglutide with daily insulin glargine, both combined with maximally tolerated doses of metformin and glimepiride in patients with type 2 diabetes.
• A 2019 study 6 compared the efficacy and safety of once-weekly dulaglutide with that of insulin glargine in combination with metformin and/or a sulphonylurea in mainly Asian patients with type 2 diabetes mellitus.

Importance of Blood Glucose Monitoring

• A 2019 study 7 emphasized the importance of blood glucose monitoring in diabetes management, highlighting its role in guiding interventions to achieve optimal glucose control and preventing diabetic-related health complications.

Treatment Outcomes and Comparisons

• The studies suggest that dulaglutide may be more effective than insulin glargine in reducing HbA1c levels and promoting weight loss, with a lower risk of hypoglycemia 4, 5, 6.
• However, dulaglutide may be associated with a higher incidence of gastrointestinal adverse events, such as nausea and diarrhea 5, 6.