From the Guidelines
Pour optimiser le traitement antidiabétique de ce patient de 75 ans avec diabète type 2 mal contrôlé, il est essentiel de considérer les bénéfices cardiovasculaires et la réduction des hospitalisations pour insuffisance cardiaque. D'abord, il faudrait ajouter un inhibiteur SGLT2 comme l'empagliflozine (10-25mg/jour) ou la dapagliflozine (10mg/jour), qui offrent des bénéfices cardiovasculaires et réduisent les hospitalisations pour insuffisance cardiaque, comme suggéré dans l'étude de 2019 1. Ensuite, considérer l'ajout d'un GLP-1 RA comme le sémaglutide (0.25mg/semaine, augmentant progressivement à 1mg) ou le dulaglutide (0.75-1.5mg/semaine), qui peuvent également aider à atteindre les objectifs glycémiques et à réduire les risques cardiovasculaires, comme discuté dans l'étude de 2020 1. La sitagliptine peut être maintenue, mais le gliclazide présente un risque d'hypoglycémie et pourrait être réduit ou arrêté si d'autres agents sont ajoutés. La metformine devrait être envisagée si non contre-indiquée par l'insuffisance cardiaque ou rénale. Une surveillance étroite de la glycémie est nécessaire après la corticothérapie, qui peut temporairement aggraver l'hyperglycémie, comme mentionné dans l'étude de 2020 1. L'éducation du patient sur l'autosurveillance glycémique, l'alimentation et l'activité physique adaptée reste essentielle pour optimiser le contrôle glycémique. Les avantages et les risques de chaque médicament doivent être soigneusement évalués, en tenant compte des comorbidités du patient, telles que l'insuffisance cardiaque et les artères cérébrales multiples sténosées, comme indiqué dans l'étude de 2019 1.
Les points clés à considérer sont :
- L'importance de la réduction des hospitalisations pour insuffisance cardiaque
- Les bénéfices cardiovasculaires des inhibiteurs SGLT2 et des GLP-1 RA
- La nécessité d'une surveillance étroite de la glycémie après la corticothérapie
- L'importance de l'éducation du patient pour optimiser le contrôle glycémique
- La prise en compte des comorbidités du patient lors de la sélection des médicaments.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION There is no fixed dosage regimen for the management of diabetes mellitus with glipizide or any other hypoglycemic agent. In elderly patients, debilitated or malnourished patients, and patients with impaired renal or hepatic function, the initial and maintenance dosing should be conservative to avoid hypoglycemic reactions
The patient is currently on sitagliptin (Januvia) 100mg and gliclazide (Diamicron) 60mg, which is higher than the maximum recommended once daily dose of 15 mg for glipizide, a similar sulfonylurea-class hypoglycemic.
- The patient's current dose of gliclazide should be reduced to avoid hypoglycemic reactions, especially considering the patient's age and recent hospitalization for decompensated heart failure.
- The patient's sitagliptin dose can be continued, but monitoring of blood glucose levels is crucial to determine the minimum effective dose.
- Close monitoring of the patient's blood glucose levels and adjustments to the dosage regimen as needed are essential to optimize anti-diabetic treatment 2.
From the Research
Optimizing Anti-Diabetic Treatment
To optimize anti-diabetic treatment for a 75-year-old man with type 2 diabetes (T2D), myocardial vascular accident (MVA), and multi-cerebral artery stenosis (MCAS), with elevated Hemoglobin A1c (HbA1c) levels, currently on sitagliptin (Januvia) 100mg and gliclazide (Diamicron) 60mg, and recently hospitalized for decompensated heart failure (HF) and treated with prednisone (Pred) for 2 days, consider the following:
- The patient's recent hospitalization for decompensated HF and treatment with prednisone may have affected his blood glucose levels, making it essential to reassess his anti-diabetic treatment regimen 3, 4.
- The use of linagliptin-basal insulin regimen has been shown to be safe, simple, and efficacious in patients with T2D and decompensated HF, with a lower total number of hypoglycemic episodes and lower total insulin dose compared to basal-bolus insulin regimen 4.
- The management of acute decompensated heart failure (ADHF) should be tailored according to the level of systolic blood pressure (SBP) at admission, renal function, and fluid retention, with the use of intravenous vasodilators and diuretics at low doses for patients with hypertensive disease, and inotropic support for patients with low output syndrome 5.
- Prior HF has been identified as the strongest predictor of future HF events, and there is an association between severe hypoglycemia and subsequent HF, highlighting the need for careful management of blood glucose levels in patients with T2D and high cardiovascular risk 6.
- In "fragile" patients, such as those with frailty syndrome (FS), the clinical features of ADHF are more pronounced, and an individualized approach to therapy is necessary, with the use of sacubitril/valsartan or dapagliflozin and quadruple therapy, to achieve optimal treatment outcomes 7.
Key Considerations
- The patient's anti-diabetic treatment regimen should be reassessed in light of his recent hospitalization for decompensated HF and treatment with prednisone.
- The use of linagliptin-basal insulin regimen may be considered as a safe and efficacious option for managing blood glucose levels in patients with T2D and decompensated HF.
- The management of ADHF should be tailored according to the patient's clinical characteristics, including SBP, renal function, and fluid retention.
- Prior HF and severe hypoglycemia are significant predictors of future HF events, and careful management of blood glucose levels is essential in patients with T2D and high cardiovascular risk.
- An individualized approach to therapy is necessary in "fragile" patients, with the use of sacubitril/valsartan or dapagliflozin and quadruple therapy, to achieve optimal treatment outcomes.