What medication should be added for a 58-year-old female with type 2 diabetes on metformin (biguanide) with an elevated HbA1c (glycated hemoglobin) level?

From the Guidelines

For a 58-year-old female with type 2 diabetes on metformin with an elevated HbA1c of 9.3, a sodium-glucose cotransporter-2 (SGLT2) inhibitor such as empagliflozin (10-25 mg daily) or dapagliflozin (5-10 mg daily) would be an appropriate addition to her treatment regimen. This recommendation is based on the most recent and highest quality study available, which suggests that SGLT2 inhibitors are effective in lowering blood glucose levels and offer additional benefits beyond glycemic control, including weight loss, blood pressure reduction, and cardiovascular and renal protection 1.

Key Considerations

• The patient's elevated HbA1c level indicates that her current treatment regimen is not adequately controlling her blood glucose levels, and additional therapy is needed to achieve and maintain individualized glycemic goals.
• SGLT2 inhibitors have been shown to be effective in reducing HbA1c levels and have a favorable safety profile, making them a suitable addition to metformin therapy 1.
• Alternatively, a glucagon-like peptide-1 (GLP-1) receptor agonist such as semaglutide (0.25 mg weekly, titrated up to 1 mg weekly) could be considered, especially if weight loss is a priority.

Important Factors to Consider

• Before starting either medication, kidney function should be assessed, and the patient should be educated about potential side effects, including genital mycotic infections with SGLT2 inhibitors or gastrointestinal symptoms with GLP-1 agonists.
• Regular monitoring of HbA1c every 3 months is recommended to assess treatment efficacy and adjust the treatment plan as needed.
• The choice of medication added to metformin should be based on the clinical characteristics of the patient and their preferences, as well as the potential benefits and risks of each medication 1.

From the FDA Drug Label

At Week 24, JARDIANCE 10 mg or 25 mg used in combination with linagliptin 5 mg provided statistically significant improvement in HbA1c (p-value <0.0001) and FPG (p-value <0. 001) compared to the individual components in patients who had been inadequately controlled on metformin. The efficacy of JARDIANCE was evaluated in a double-blind, glimepiride-controlled, study in 1545 patients with type 2 diabetes with insufficient glycemic control despite metformin therapy Patients with inadequate glycemic control and an HbA1c between 7% and 10% after a 2-week run-in period were randomized to glimepiride or JARDIANCE 25 mg. At Week 52, JARDIANCE 25 mg and glimepiride lowered HbA1c and FPG

The medication that should be added for a 58-year-old female with type 2 diabetes on metformin with an elevated HbA1c level is empagliflozin (JARDIANCE), as it has been shown to provide statistically significant improvement in HbA1c and FPG in patients inadequately controlled on metformin 2.

• Key benefits of empagliflozin include:
  • Statistically significant improvement in HbA1c
  • Statistically significant improvement in FPG
  • Statistically significant reduction in body weight
• Important considerations: The patient's HbA1c level is 9.3, which is above the target range, and empagliflozin has been shown to be effective in lowering HbA1c levels in patients with type 2 diabetes who are inadequately controlled on metformin.

From the Research

Medication Options for Type 2 Diabetes

Given the patient's current medication regimen of metformin and an elevated HbA1c level of 9.3, additional medication may be necessary to achieve better glycemic control. The following options can be considered:

• Dipeptidyl Peptidase-4 (DPP-4) Inhibitors: These medications, such as sitagliptin, have been shown to improve metabolic control in type 2 diabetes, both as monotherapy and in combination with metformin 3. They have a favorable safety profile, are highly tolerable, and have a minimal risk of hypoglycemia.
• Glucagon-like Peptide-1 (GLP-1) Receptor Agonists: Although GLP-1 receptor agonists may be more potent in improving glucose control and promoting weight reduction, they may have a higher risk of adverse effects, such as nausea and vomiting, and are typically more expensive than DPP-4 inhibitors 4.
• Sodium-Glucose Cotransporters Type 2 (SGLT2) Inhibitors: These medications, also known as gliflozins, may be considered as an alternative to sulphonylureas, especially in patients at risk of hypoglycemia 5. However, they may be more suitable for patients with obesity, hypertension, or a history of cardiovascular disease.

Key Considerations

When selecting an additional medication, the following factors should be taken into account:

• Efficacy in reducing HbA1c levels
• Safety profile and risk of adverse effects
• Cost and patient preference
• Individual patient characteristics, such as renal function, body weight, and cardiovascular risk factors 6, 7, 5

Potential Benefits and Drawbacks

The potential benefits and drawbacks of each medication option should be carefully weighed, including:

• DPP-4 inhibitors: favorable safety profile, minimal risk of hypoglycemia, but may be less potent than GLP-1 receptor agonists 6, 3
• GLP-1 receptor agonists: more potent in improving glucose control, but may have a higher risk of adverse effects and are typically more expensive 4
• SGLT2 inhibitors: may be suitable for patients with obesity or cardiovascular disease, but may have a higher risk of urinary or genital infections 5