What are the next steps for a patient with suboptimal glycemic control on metformin (biguanide) 1g twice daily (bid) and glipizide (sulfonylurea) 10mg bid, with hyperglycemia, considering adding Jardiance (empagliflozin, sodium-glucose cotransporter 2 inhibitor)?

From the Guidelines

For a patient with suboptimal glycemic control on metformin 1g bid and glipizide 10mg bid, adding Jardiance (empagliflozin) 10mg once daily is an appropriate next step, as it can help achieve individualized glycemic goals and provide cardiovascular and renal benefits, as recommended by the 2025 standards of care in diabetes 1. The patient should start with 10mg daily in the morning, which can be increased to 25mg daily if needed after 4-12 weeks based on glycemic response and tolerability. Before initiating Jardiance, assess renal function as it should not be started if eGFR is below 30 ml/min/1.73m², as indicated by the 2021 kdigo clinical practice guideline on diabetes management in chronic kidney disease 1. Patients should be educated about potential side effects including genital mycotic infections, urinary tract infections, and volume depletion, as well as the rare but serious risk of diabetic ketoacidosis. Jardiance works by inhibiting SGLT2 in the proximal renal tubules, preventing glucose reabsorption and increasing urinary glucose excretion, which lowers blood glucose independently of insulin. Some key points to consider when adding Jardiance to the treatment regimen include:

• Monitoring renal function and adjusting the dose as needed
• Educating patients about potential side effects and risks
• Considering the patient's individualized glycemic goals and adjusting the treatment plan accordingly
• Being aware of the potential benefits of Jardiance, including cardiovascular and renal benefits, as highlighted in the 2020 standards of medical care in diabetes 1 and the 2019 scientific statement from the american heart association and the heart failure society of america 1. Regular monitoring of renal function, blood pressure, and glycemic control is essential after initiating this medication.

From the FDA Drug Label

as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus The recommended dose of JARDIANCE is 10 mg once daily, taken in the morning, with or without food Consider lowering the dose of insulin secretagogue or insulin to reduce the risk of hypoglycemia when initiating JARDIANCE

The patient with an A1c of 8.2 on metformin 1g bid and glipizide 10mg bid may be a candidate for adding Jardiance (empagliflozin) to improve glycemic control. Key considerations include:

• Assessing renal function before initiating JARDIANCE
• Monitoring for signs and symptoms of hypoglycemia and adjusting the dose of insulin secretagogue or insulin as needed
• Evaluating the patient's overall clinical situation to determine the best course of treatment 2, 2

From the Research

Patient Profile

• The patient has an HbA1c of 8.2%, indicating suboptimal glycemic control.
• The patient is currently on metformin 1g twice daily (bid) and glipizide 10mg bid.

Treatment Considerations

• According to the American Diabetes Association (ADA) guidelines, as mentioned in the study 3, if the HbA1c target is not achieved or maintained by metformin monotherapy at maximal tolerated dose over 3 to 6 months, treatment modification with addition of a second oral antihyperglycemic agent or by initiating insulin is recommended.
• A study comparing empagliflozin and glimepiride as add-on to metformin in patients with type 2 diabetes 4 found that empagliflozin was non-inferior to glimepiride at both 52 and 104 weeks, and had a lower risk of hypoglycemic adverse events.
• The addition of Jardiance (empagliflozin) to the patient's current treatment regimen may be considered, as it has been shown to be effective in improving glycemic control and reducing the risk of hypoglycemia compared to sulfonylureas like glipizide.

Factors to Consider

• The patient's age, duration of diabetes, and presence of comorbidities such as hypertension, hyperlipidemia, and renal disease may influence the treatment decision, as these factors have been associated with suboptimal glycemic control 3, 5.
• The patient's current HbA1c level and body mass index (BMI) may also be important factors to consider, as higher baseline HbA1c and BMI have been associated with suboptimal glycemic control 5.

Next Steps

• Consider adding Jardiance (empagliflozin) to the patient's current treatment regimen, taking into account the patient's individual characteristics and medical history.
• Monitor the patient's HbA1c levels and adjust the treatment regimen as needed to achieve optimal glycemic control.
• Consider the potential benefits and risks of adding Jardiance, including the reduced risk of hypoglycemia and the potential for improved glycemic control, as well as the potential for increased cost and the need for regular monitoring of renal function and other potential side effects.