What medications should someone with severe hyperglycemia (HbA1c of 13.2) be started on?

From the Guidelines

For severe hyperglycemia with an HbA1c of 13.2%, immediate initiation of insulin therapy is typically recommended, often with a basal-bolus regimen, as it is the most effective approach to rapidly achieve glycemic control and prevent complications 1. This approach is supported by recent guidelines, which suggest that insulin therapy should be considered as part of any combination regimen when hyperglycemia is severe, especially if catabolic features are present 1. The recommended starting doses are generally weight-based, with approximately 0.5-0.7 units/kg/day total insulin, divided as 50% basal and 50% bolus 1. Alongside insulin, metformin (starting at 500 mg once or twice daily, increasing to 1000 mg twice daily as tolerated) is often added unless contraindicated, as it addresses both fasting and postprandial glucose levels 1. Some key points to consider when initiating insulin therapy include:

• Starting with a long-acting insulin such as insulin glargine (Lantus) or insulin detemir (Levemir) once daily, combined with rapid-acting insulin (like insulin lispro, aspart, or glulisine) before meals
• Monitoring glucose patterns closely and adjusting medication dosing as needed
• Providing education on glucose monitoring, hypoglycemia management, and lifestyle modifications
• Considering additional oral medications like SGLT-2 inhibitors (empagliflozin, dapagliflozin) or GLP-1 receptor agonists (semaglutide, dulaglutide) in some cases 1. It's worth noting that the most recent study 1 focuses on children and adolescents, but the general principle of initiating insulin therapy for severe hyperglycemia is still applicable to adults, and the recommendations from 1 are more relevant to this specific question.

From the FDA Drug Label

The provided drug labels do not directly address the specific question of what medications someone with an HbA1c of 13.2 should be started on.

The FDA drug label does not answer the question.

From the Research

Medication Options for Severe Hyperglycemia

For someone with an HbA1c of 13.2, indicating severe hyperglycemia, the following medication options can be considered:

• Metformin: often the first-line treatment for type 2 diabetes, but may not be sufficient for severe hyperglycemia 2, 3
• SGLT2 inhibitors: have been shown to have cardiovascular and renal protective effects, and can be used in combination with other medications 4, 5, 6
• GLP-1 receptor agonists: also have cardiovascular and renal protective effects, and can be used in combination with SGLT2 inhibitors 4, 5, 6
• Pioglitazone: can be used in combination with metformin and SGLT2 inhibitors, but may have adverse effects such as weight gain and increased risk of heart failure 2, 3

Combination Therapy

Combination therapy with multiple medications can be effective in achieving better glycemic control and reducing cardiovascular risk:

• Metformin + SGLT2 inhibitor + GLP-1 receptor agonist: has been shown to have additive effects on lowering HbA1c and systolic blood pressure, and reducing cardiovascular risk 4, 2, 6
• Metformin + pioglitazone + SGLT2 inhibitor + GLP-1 receptor agonist: has been shown to have favorable cardiorenal outcomes, but may have adverse effects such as weight gain and increased risk of heart failure 2, 3

Considerations

When selecting medications for someone with severe hyperglycemia, the following factors should be considered:

• Individual patient profile: including medical history, comorbidities, and lifestyle factors 5
• Specificities of each molecule: including mechanism of action, efficacy, and adverse effects 5, 6
• Potential for combination therapy: including additive effects and potential adverse effects 4, 2, 6