Is it appropriate to increase Metaglip to QID and add Jardiance for a type 2 diabetic patient with hyperglycemia on Metaglip 5/500 mg TID who refuses insulin?

From the Guidelines

Increasing Metaglip to QID and adding Jardiance is an appropriate approach for a type 2 diabetic patient with hyperglycemia who refuses insulin, as it allows for intensification of therapy while respecting the patient's preference to avoid insulin. For the Metaglip (glipizide/metformin) increase, I recommend going from 5/500 mg TID to 5/500 mg QID, which would provide better coverage throughout the day. Adding Jardiance (empagliflozin) at a starting dose of 10 mg once daily (can be increased to 25 mg daily if needed) would complement this regimen through a different mechanism of action, as suggested by the 2022 consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) 1. This combination addresses hyperglycemia through multiple pathways: Metaglip increases insulin secretion and improves insulin sensitivity, while Jardiance promotes urinary glucose excretion.

Before implementing this change, baseline renal function should be assessed since Jardiance requires adequate kidney function (eGFR ≥45 mL/min/1.73m²) 1. The patient should be monitored for side effects including hypoglycemia, urinary tract infections, genital mycotic infections, and volume depletion. According to the 2020 standards of medical care in diabetes, the choice of medication added to metformin is based on the clinical characteristics of the patient and their preferences, and Jardiance is a suitable option for patients with type 2 diabetes who require additional glucose-lowering therapy 1.

Key considerations for this approach include:

• Monitoring for potential side effects and adjusting the regimen as needed
• Regular assessment of renal function and adjustment of Jardiance dosage accordingly
• Patient education on the importance of adherence to the medication regimen and monitoring for signs of hypoglycemia or other side effects
• Consideration of the patient's overall clinical profile, including the presence of any comorbidities or risk factors for adverse events.

From the FDA Drug Label

JARDIANCE has been studied as monotherapy and in combination with metformin, sulfonylurea, pioglitazone, linagliptin, and insulin. In patients with type 2 diabetes, treatment with JARDIANCE reduced hemoglobin A1c (HbA1c), compared to placebo Add-On Combination Therapy with Metformin A total of 637 patients with type 2 diabetes participated in a double-blind, placebo-controlled study to evaluate the efficacy and safety of JARDIANCE in combination with metformin

For a type 2 diabetic patient with an A1c of 10.3, on Metaglip 5/500 mg TID and not wanting to start insulin, increasing Metaglip to QID and adding Jardiance may be considered. The patient's current A1c level is higher than the range (7-10%) in the studies evaluating JARDIANCE in combination with metformin. However, the studies demonstrate that JARDIANCE can reduce HbA1c levels in patients with type 2 diabetes.

• Key considerations:
  • The patient's high A1c level (10.3%) indicates inadequate glycemic control on the current Metaglip regimen.
  • JARDIANCE has been shown to reduce HbA1c levels in patients with type 2 diabetes, including those on metformin.
  • Increasing Metaglip to QID may increase the risk of hypoglycemia or other adverse effects.
• Clinical decision: Increasing Metaglip to QID and adding Jardiance may be a viable option for this patient, but it is essential to closely monitor the patient's glycemic control, renal function, and potential adverse effects 2, 2.

From the Research

Treatment Options for Type 2 Diabetes

For a type 2 diabetic patient with an A1c of 10.3, who is currently on Metaglip 5/500 mg TID and refuses to start insulin, the following options can be considered:

• Increasing Metaglip to QID: There is no direct evidence to support the efficacy and safety of increasing Metaglip to QID in patients with type 2 diabetes 3.
• Adding Jardiance: Jardiance (empagliflozin) is an SGLT2 inhibitor that has been shown to improve glycemic control and reduce cardiovascular risk in patients with type 2 diabetes 4. However, there is no specific evidence to support the use of Jardiance in combination with Metaglip in patients who refuse insulin.

Alternative Treatment Options

Other treatment options that can be considered for this patient include:

• GLP-1 receptor agonists: These agents have been shown to improve glycemic control and reduce body weight and systolic blood pressure in patients with type 2 diabetes 5, 6.
• DPP-4 inhibitors: These agents have been shown to improve glycemic control without increasing the risk of hypoglycemia or weight gain in patients with type 2 diabetes 5, 6.

Considerations for Treatment Selection

When selecting a treatment option for this patient, the following factors should be considered:

• Efficacy: The ability of the treatment to improve glycemic control and reduce cardiovascular risk.
• Safety: The potential risks and side effects associated with the treatment.
• Patient preference: The patient's willingness to accept a particular treatment, including the route of administration and potential side effects.
• Clinical characteristics: The patient's clinical characteristics, including their A1c level, body weight, and cardiovascular risk factors.