What is the best medication for a 77-year-old male with coronary artery disease (CAD) stents, peripheral arterial disease (PAD), and a history of pancreatitis while on Bydureon (exenatide) with an elevated Hemoglobin A1C (HbA1c) level?

From the Guidelines

For a 77-year-old male with CAD stents, PAD, history of pancreatitis while on exenatide, and elevated HbA1c, a sodium-glucose cotransporter-2 (SGLT2) inhibitor such as empagliflozin (Jardiance) 10mg daily would be the recommended medication, as this class of medication has demonstrated cardiovascular benefits in patients with established cardiovascular disease, including reduced risk of major adverse cardiovascular events and heart failure hospitalizations 1.

Key Considerations

• The patient's history of pancreatitis with exenatide necessitates careful monitoring if another GLP-1 agonist, such as semaglutide (Ozempic) 0.25mg weekly initially, titrated to 0.5mg weekly after 4 weeks, is considered 1.
• Metformin 500-1000mg twice daily should be used alongside the chosen medication if tolerated and not contraindicated by renal function 1.
• Comprehensive cardiovascular risk management is crucial, including antiplatelet therapy (aspirin 81mg daily), high-intensity statin therapy (atorvastatin 40-80mg daily), and blood pressure control 1.
• Regular monitoring of renal function is essential, particularly with SGLT2 inhibitors, and the patient should be educated about hypoglycemia recognition and management, especially if insulin is part of the regimen 1.

Additional Recommendations

• The treatment approach should prioritize the patient's individual characteristics, preferences, and access to therapies 1.
• Glycemic control should be evaluated on an ongoing basis, using measures such as A1C, time in range (TIR), and glucose management indicator (GMI) data from patients’ continuous glucose monitoring (CGM) or self-monitoring of blood glucose (SMBG) devices 1.

From the FDA Drug Label

The effect of JARDIANCE on cardiovascular risk in adult patients with type 2 diabetes and established, stable, atherosclerotic cardiovascular disease was evaluated in the EMPA-REG OUTCOME study, a multicenter, multi-national, randomized, double-blind parallel group trial JARDIANCE significantly reduced the risk of first occurrence of primary composite endpoint of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke (HR: 0.86; 95% CI 0.74,0. 99)

The best medication for a 77-year-old male with coronary artery disease (CAD) stents, peripheral arterial disease (PAD), and a history of pancreatitis while on Bydureon (exenatide) with an elevated Hemoglobin A1C (HbA1c) level of 10.2 is empagliflozin (JARDIANCE), as it has been shown to reduce the risk of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke in patients with type 2 diabetes and established atherosclerotic cardiovascular disease 2.

• Key benefits of empagliflozin include:
  • Reduced risk of cardiovascular death
  • Reduced risk of non-fatal myocardial infarction or non-fatal stroke
• Important considerations:
  • Patient's history of pancreatitis while on Bydureon (exenatide) should be monitored closely
  • Renal function should be assessed before initiating empagliflozin therapy 2

From the Research

Medication Options for A1C 10.2 in 77-year-old Male with CAD Stents, PAD, and History of Pancreatitis

• The patient's history of pancreatitis while on Bydureon (exenatide) suggests that medications with a lower risk of pancreatitis should be considered 3.
• Empagliflozin, an SGLT2 inhibitor, has been shown to be effective in reducing HbA1c levels in patients with type 2 diabetes, with a lower risk of hypoglycemia compared to sulfonylureas 4, 5.
• However, there have been reports of empagliflozin-associated pancreatitis, although the association is not established 3.
• Other medication options, such as metformin, sulfonylureas, and glipizide, may also be considered, but their efficacy and safety profiles should be evaluated in the context of the patient's medical history and current condition 6, 7.

Considerations for Medication Selection

• The patient's age, medical history, and current condition should be taken into account when selecting a medication 6.
• The risk of hypoglycemia, weight gain, and other adverse effects should be considered when choosing a medication 4, 5.
• The patient's history of pancreatitis while on Bydureon (exenatide) suggests that medications with a lower risk of pancreatitis should be prioritized 3.

Empagliflozin as a Potential Option

• Empagliflozin has been shown to be effective in reducing HbA1c levels in patients with type 2 diabetes, with a lower risk of hypoglycemia compared to sulfonylureas 4, 5.
• However, the risk of empagliflozin-associated pancreatitis should be carefully evaluated in the context of the patient's medical history 3.
• The benefits and risks of empagliflozin should be weighed against other medication options, considering the patient's individual needs and circumstances 7.