What is the next medication to add for a 54-year-old patient with hyperglycemia (elevated A1C of 9.1%) on Metformin (Metformin) 1000mg twice daily (bid) and Trulicity (Dulaglutide) 4.5mg weekly, who is reluctant to start daily insulin injections?

From the Guidelines

For a 54-year-old patient with an A1C of 9.1% who is already on maximum Metformin and Trulicity but reluctant to start insulin, the next appropriate medication to add would be an SGLT-2 inhibitor such as empagliflozin (Jardiance) 10mg daily, increasing to 25mg daily if needed and tolerated. This recommendation is based on the most recent and highest quality study available, which suggests that SGLT-2 inhibitors can provide additional benefits beyond glycemic control, including cardiovascular protection, weight loss, and reduced risk of heart failure hospitalization 1. The patient's current regimen of Metformin and Trulicity has not achieved the desired glycemic control, and the addition of an SGLT-2 inhibitor can help to further lower their A1C levels. Some key points to consider when prescribing empagliflozin include:

• The recommended dose is 10mg daily, which can be increased to 25mg daily if needed and tolerated
• SGLT-2 inhibitors can cause genital mycotic infections and increased urination, so patients should be advised to maintain adequate hydration and practice good genital hygiene
• Empagliflozin has been shown to provide renal protection in patients with diabetic kidney disease, which may be beneficial for this patient
• The medication should be initiated at the lowest dose tested in CV and renal outcomes trials, with no further dose titration needed for CV or renal risk reduction, but dose increases may provide further glucose reduction benefits if indicated 1. It's also important to note that the choice of medication added to metformin is based on the clinical characteristics of the patient and their preferences, and SGLT-2 inhibitors are a good option for patients with established ASCVD or indicators of high ASCVD risk, other comorbidities, and risk for specific adverse drug effects 1. Additionally, a recent consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO) provides guidance on the use of SGLT-2 inhibitors in patients with chronic kidney disease, and recommends that the dose be adjusted based on the patient's eGFR 1. Overall, the addition of empagliflozin to this patient's current regimen can provide effective glycemic control and additional benefits, while addressing their reluctance toward insulin therapy.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Options for Type 2 Diabetes

The patient is currently on Metformin 1000mg twice daily and Trulicity 4.5mg weekly, with an A1C of 9.1%. To bring down the A1C, the next medication to consider would be an SGLT2 inhibitor, such as empagliflozin, dapagliflozin, or canagliflozin 2, 3, 4.

Benefits of SGLT2 Inhibitors

SGLT2 inhibitors have been shown to:

• Reduce blood glucose levels by increasing urinary glucose excretion 4
• Provide additional reductions in body weight and blood pressure 3
• Have a low risk of hypoglycemia 3, 4
• Be effective in combination with other antidiabetic medications, including metformin and GLP-1 receptor agonists like Trulicity 3, 5, 6

Combination Therapy with DPP-4 Inhibitors

Combining an SGLT2 inhibitor with a DPP-4 inhibitor, such as saxagliptin or linagliptin, may also be considered 5, 6. This combination has been shown to be safe and effective in reducing blood glucose levels, with a low risk of hypoglycemia.

Potential Next Steps

Based on the available evidence, potential next steps for this patient could include:

• Adding an SGLT2 inhibitor, such as empagliflozin or dapagliflozin, to the current medication regimen 2, 4
• Considering a combination of an SGLT2 inhibitor and a DPP-4 inhibitor, such as saxagliptin or linagliptin, if the patient's glycemic control is not adequate with an SGLT2 inhibitor alone 5, 6