From the Guidelines
A patient with an A1C level of 15 requires immediate initiation of insulin therapy, starting with 10 units per day or 0.1-0.2 units/kg per day of basal analog or bedtime NPH insulin, as recommended by the most recent guidelines 1. This approach is necessary due to the severely uncontrolled diabetes, which corresponds to an average blood glucose level of approximately 400 mg/dL, significantly increasing the risk for microvascular complications and macrovascular disease. The patient should be evaluated urgently for potential complications such as diabetic ketoacidosis, hyperglycemic hyperosmolar state, and end-organ damage. Key aspects of management include:
- Initiating insulin therapy with a basal analog or bedtime NPH insulin, with a starting dose of 10 units per day or 0.1-0.2 units/kg per day 1
- Setting a fasting plasma glucose (FPG) goal and choosing an evidence-based titration algorithm to adjust the insulin dose 1
- Considering the addition of a GLP-1 RA or dual GIP and GLP-1 RA if the A1C remains above goal, as these therapies may provide additional glucose-lowering benefits with favorable weight, cardiovascular, kidney, and liver profiles 1
- Implementing lifestyle modifications, including carbohydrate restriction, regular physical activity, and blood glucose monitoring 3-4 times daily
- Ensuring hydration by drinking plenty of water Regular follow-up within 1-2 weeks is crucial to adjust medication dosing based on blood glucose readings and to assess the adequacy of the insulin dose, considering clinical signals for overbasalization and the need for adjunctive therapies 1.
From the Research
Patient with A1C Level of 15
For a patient with an A1C level of 15, the following steps can be considered:
- Monitor treatment regimens more carefully and encourage healthy behaviors 2
- Intensify pharmacological treatment as needed 2
- Consider combination therapy with GLP-1 receptor agonist and SGLT2 inhibitor, which has been shown to effectively reduce HbA1c levels 3
- Switch to or add medications such as empagliflozin or dulaglutide, which have been shown to be effective in reducing HbA1c levels in patients with type 2 diabetes 4
Medication Options
Some medication options that can be considered for a patient with an A1C level of 15 include:
- GLP-1 receptor agonists, which have been shown to reduce HbA1c levels and have positive effects on weight 5, 3
- SGLT2 inhibitors, which have been shown to reduce HbA1c levels and have positive effects on weight and cardiovascular outcomes 5, 3
- Empagliflozin, which has been shown to be effective in reducing HbA1c levels and body weight in patients with type 2 diabetes 4
- Dulaglutide, which has been shown to be effective in reducing HbA1c levels in patients with type 2 diabetes 4
Potential Complications
It is also important to note that an A1C level of 15 may be associated with a higher incidence of postoperative complications, such as infections, in patients with diabetes 6. Therefore, careful monitoring and management of blood glucose levels is crucial to prevent these complications.