How to manage a patient with increased HbA1c from 7.4 to 8.3 after medication adjustments?

From the Guidelines

To manage a patient with an increased HbA1c from 7.4 to 8.3 after medication adjustments, I recommend intensifying the current diabetes treatment regimen by adding a second agent to metformin, such as a GLP-1 receptor agonist or an SGLT-2 inhibitor, while continuing to monitor and adjust the glipizide dose as needed to minimize the risk of hypoglycemia. The patient is currently on metformin 1000 mg BD and glipizide 10 mg once a day, and the recent increase in HbA1c suggests that the current regimen is not sufficient to achieve adequate glycemic control. According to the American Diabetes Association standards of medical care in diabetes 1, when monotherapy with a noninsulin agent at the maximum tolerated dose does not achieve or maintain the HbA1c target over 3 months, a second agent should be added. Some key points to consider when managing this patient include:

• Reviewing medication adherence and addressing any barriers the patient may be experiencing
• Considering the addition of a second agent, such as a GLP-1 receptor agonist (like semaglutide 0.25 mg weekly, titrated up to 1 mg weekly) or an SGLT-2 inhibitor (such as empagliflozin 10 mg daily), to metformin
• Emphasizing lifestyle modifications, including dietary changes, regular physical activity (150 minutes weekly), and weight management
• Monitoring for hypoglycemia, particularly in patients on glipizide, and adjusting the dose as needed to minimize this risk, as recommended by the International Hypoglycemia Study Group 1
• Scheduling follow-up in 3 months to reassess HbA1c and adjust the treatment plan as needed. The use of blood glucose monitoring in individuals on noninsulin therapies, such as the patient's current regimen, may be helpful when altering diet, physical activity, and/or medications in conjunction with a treatment adjustment program 1.

From the FDA Drug Label

The results are presented in Table 7 Table 7: Mean Change in Fasting Plasma Glucose and HbA1c at Week 29 Comparing Metformin Hydrochloride Tablets vs Placebo in Patients with Type 2 Diabetes Mellitus *Not statistically significant Metformin Hydrochloride Tablets (n=141) Placebo (n=145) p-Value FPG (mg/dL) Baseline 241.5 237.7 NS * Change at FINAL VISIT –53.0 6.3 0.001 Hemoglobin A1c (%) Baseline 8.4 8.2 NS * Change at FINAL VISIT –1. 4 0.4 0.001

The patient's HbA1c has increased from 7.4 to 8.3 after medication adjustments.

• The patient is currently on metformin 1000 mg BD and glipizide 10 mg once a day.
• The metformin label shows that it can decrease HbA1c levels, but the current dosage may not be sufficient to achieve the desired level.
• Consider increasing the metformin dose or adding another medication to achieve better glycemic control.
• However, without more information about the patient's condition and medication history, it's difficult to make a specific recommendation.
• It's also important to consider the patient's cost problem with jardiance and find alternative solutions that are affordable. 2

From the Research

Management of Patient with Increased HbA1c

The patient's HbA1c has increased from 7.4 to 8.3 after medication adjustments, which included continuing metformin, reducing glipizide to 10 mg once a day, and stopping jardiance due to cost issues. To manage this patient, consider the following options:

• Re-evaluate the patient's medication regimen and consider adding or adjusting medications to achieve better glycemic control 3, 4, 5.
• Consider the patient's baseline characteristics, such as HbA1c level, renal function, and age, when choosing between different medication classes, such as dipeptidyl peptidase-4 inhibitors (DPP-4i) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) 5.
• Insulin therapy may be considered if the patient's HbA1c level remains high despite adjustments to oral medications 3, 6.

Medication Adjustments

Some potential medication adjustments to consider include:

• Adding a DPP-4i, such as sitagliptin, to the patient's metformin and glipizide regimen, as this combination has been shown to improve HbA1c levels in patients with type 2 diabetes 4.
• Considering the use of an SGLT2i, such as canagliflozin, as an add-on to metformin, as this class of medications has been shown to improve HbA1c levels and reduce the risk of cardiovascular events 3, 5.
• Adjusting the patient's glipizide dose or switching to a different sulfonylurea, such as glimepiride, to minimize the risk of hypoglycemia 4.

Monitoring and Follow-up

Regular monitoring of the patient's HbA1c level, renal function, and other cardiovascular risk factors is crucial to adjust the treatment plan as needed and minimize the risk of complications 7.