What is the best next step for an 80-year-old patient with Type 2 Diabetes Mellitus (T2DM) on metformin (Metformin) 1000 mg twice a day (BID) and Lantus (Insulin Glargine) 20 units/day with an elevated Hemoglobin A1C (HbA1C) level?

From the Guidelines

For an 80-year-old patient with T2DM on metformin 1000 mg BID and Lantus 20 units/day who has an elevated HbA1C of 11.5, the best next step would be to increase the Lantus dose by 2-4 units while closely monitoring for hypoglycemia, as this gradual insulin titration approach is safer in elderly patients who are at higher risk for hypoglycemic events, as recommended by the American Diabetes Association standards of medical care in diabetes 1.

When considering the management of this patient, it's essential to balance the need for improved glycemic control with the heightened risks of aggressive treatment in elderly patients. The primary goals in this age group shift toward preventing acute complications rather than targeting the same strict HbA1C goals as in younger patients.

• The patient's current regimen includes metformin, which is the preferred initial pharmacologic agent for T2DM due to its efficacy, safety, and potential to reduce the risk of cardiovascular events and death 1.
• The addition of basal insulin, such as Lantus, is appropriate for patients who do not achieve their HbA1C targets with metformin alone, and gradual titration of the insulin dose is recommended to minimize the risk of hypoglycemia 1.
• Considering the patient's elevated HbA1C level, increasing the Lantus dose is a reasonable next step, but it's crucial to monitor the patient closely for signs of hypoglycemia and adjust the dose accordingly.
• Additionally, the use of a GLP-1 receptor agonist, such as semaglutide, could be considered to improve glycemic control without significantly increasing the risk of hypoglycemia, although this would depend on the patient's specific clinical circumstances and preferences.
• Regular blood glucose monitoring should be implemented, ideally before meals and at bedtime, with a target fasting glucose of 90-150 mg/dL for this age group, as recommended by the American College of Physicians guidance statement update on HbA1C targets for glycemic control with pharmacologic therapy for nonpregnant adults with type 2 diabetes mellitus 1.

From the FDA Drug Label

2 DOSAGE AND ADMINISTRATION

2.2 General Dosing Instructions Administer Insulin Glargine subcutaneously once daily at any time of day but at the same time every day. Individualize and adjust the dosage of Insulin Glargine based on the patient's metabolic needs, blood glucose monitoring results and glycemic control goal. Dosage adjustments may be needed with changes in physical activity, changes in meal patterns (i.e., macronutrient content or timing of food intake), during acute illness, or changes in renal or hepatic function. Dosage adjustments should only be made under medical supervision with appropriate glucose monitoring [see Warnings and Precautions (5.2)].

The best next step for an 80-year-old patient with Type 2 Diabetes Mellitus (T2DM) on metformin 1000 mg twice a day and Lantus 20 units/day with an elevated Hemoglobin A1C (HbA1C) level of 11.5 is to adjust the dosage of Insulin Glargine based on the patient's metabolic needs and blood glucose monitoring results.

• The patient's current dosage of Lantus is 20 units/day, which may need to be increased to achieve better glycemic control.
• Dosage adjustments should be made under medical supervision with appropriate glucose monitoring to minimize the risk of hypoglycemia or other adverse effects.
• It is also important to monitor the patient's renal function and adjust the metformin dosage as needed, as the patient's age and potential renal impairment may increase the risk of lactic acidosis 2.
• The patient's treatment plan should be individualized to take into account their specific needs and health status 3.

From the Research

Patient Profile

• Age: 80 years
• Diagnosis: Type 2 Diabetes Mellitus (T2DM)
• Current medication: Metformin 1000 mg twice a day (BID) and Lantus (Insulin Glargine) 20 units/day
• Hemoglobin A1C (HbA1C) level: 11.5

Considerations for Next Steps

• The patient's elevated HbA1C level indicates poor glycemic control 4
• Studies suggest that maintaining A1C levels within individualized target ranges is associated with lower risk of mortality and cardiovascular disease in older adults with diabetes 4
• The choice of second-line glucose-lowering medication class added to metformin may not be associated with change in cognitive performance in persons with early T2D, but worse glycemic control is associated with modestly worse cognitive performance 5
• Combination therapy with an SGLT2 inhibitor as initial treatment for Type 2 Diabetes has been shown to have glycaemic and weight benefits compared with either agent alone 6

Potential Next Steps

• Consider adjusting the patient's medication regimen to improve glycemic control, such as increasing the dose of metformin or adding a new medication 4, 6
• Monitor the patient's HbA1C levels regularly to assess the effectiveness of any changes to their medication regimen 4
• Consider the patient's individualized target range for A1C levels, taking into account their age, comorbidities, and other factors 4