What is the next step to improve glycemic control in a patient with an HbA1c of 9.3% on glipizide and Jardiance?

From the Guidelines

The next step to improve glycemic control in this patient would be to add basal insulin, such as insulin glargine, to the current regimen of glipizide and Jardiance, as GLP-1 receptor agonists are not an option due to insurance constraints. With an HbA1c of 9.3% while already on a sulfonylurea (glipizide) and an SGLT2 inhibitor (Jardiance), the patient requires additional therapy to reach the target HbA1c of less than 7% 1. According to the American Diabetes Association standards of medical care in diabetes, insulin therapy should not be delayed in patients not achieving glycemic goals, and basal insulin may be initiated at 10 units or 0.1 to 0.2 units/kg of body weight 1. Some key points to consider when adding basal insulin include:

• Starting with a low dose, such as 10 units at bedtime, and titrating up as needed based on fasting glucose readings
• Adjusting the dose of basal insulin to achieve a fasting glucose target, while also considering the risk of hypoglycemia
• Continuing to monitor HbA1c levels every 3 to 6 months to assess the success of the treatment regimen 1 The combination of medications with different mechanisms of action (increasing insulin secretion with glipizide, reducing glucose reabsorption with Jardiance, and providing exogenous insulin) addresses multiple pathophysiological defects in type 2 diabetes, which is necessary when the HbA1c remains significantly elevated on dual therapy.

From the FDA Drug Label

A total of 563 patients with type 2 diabetes inadequately controlled on multiple daily injections (MDI) of insulin (total daily dose >60 IU), alone or in combination with metformin, participated in a double-blind, placebo-controlled study to evaluate the efficacy of JARDIANCE as add-on therapy to MDI insulin over 18 weeks JARDIANCE 10 mg or 25 mg daily used in combination with MDI insulin (with or without metformin) provided statistically significant reductions in HbA1c compared to placebo after 18 weeks of treatment

The patient is already on Jardiance. To improve glycemic control, insulin could be considered as an add-on therapy, as the patient is already on glipizide and Jardiance, and GLP-1s are not an option.

• The patient's current HbA1c is 9.3%, indicating inadequate glycemic control.
• The addition of insulin to the patient's current regimen may help achieve better glycemic control, as seen in the study where JARDIANCE was used in combination with MDI insulin. 2

From the Research

Current Medication Regimen

The patient is currently on glipizide 2 mg twice daily and Jardiance (empagliflozin) 25 mg daily, with an HbA1c of 9.3%. Given the patient's allergy to metformin and the fact that GLP-1s are not an option due to insurance coverage, alternative treatments need to be considered to improve glycemic control.

Potential Treatment Options

• Increasing the dose of glipizide: According to the study 3, glipizide can be given once-daily without loss of therapeutic effect. However, the patient is already taking 2 mg twice daily, so increasing the dose may not be the most effective option.
• Adding another medication: Since the patient is already on a sulfonylurea (glipizide) and an SGLT2 inhibitor (empagliflozin), another medication with a different mechanism of action could be considered. However, there is no clear evidence to support the addition of a specific medication in this scenario.
• Optimizing the current regimen: The study 4 showed that empagliflozin twice daily was non-inferior to once daily, but this may not be relevant in this case since the patient is already taking the medication once daily.

Considerations

• The patient's HbA1c is 9.3%, indicating poor glycemic control. Therefore, any changes to the medication regimen should aim to improve glycemic control while minimizing the risk of hypoglycemia and other adverse effects.
• The study 5 demonstrated the efficacy and safety of empagliflozin as add-on therapy to pioglitazone or pioglitazone plus metformin in patients with type 2 diabetes. However, this may not be directly applicable to this patient's situation due to the metformin allergy.
• The study 6 highlighted the benefits of empagliflozin in patients with type 2 diabetes, including its cardioprotective and renoprotective properties. However, this does not provide guidance on how to improve glycemic control in this specific patient.
• The study 7 examined the pharmacokinetics of glipizide, but did not provide information on how to optimize the medication regimen in this patient.

Next Steps

Given the limited options and the lack of clear evidence to support a specific treatment approach, it may be necessary to consider other medications or treatment strategies not mentioned in the provided studies. However, based on the available evidence, it is clear that the patient's current medication regimen is not providing adequate glycemic control, and alternative options should be explored.