How to optimize anti-diabetic treatment for a 75-year-old man with type 2 diabetes (T2D), history of myocardial vascular accident (MVA) and multi-cerebral artery stenosis (MCAS), with elevated Hemoglobin A1c (HbA1c) level, currently on sitagliptin (100mg) and recently increased gliclazide (from 30 to 60mg), who has been hospitalized for decompensated heart failure (HF) and received prednisone for 2 days, and has a history of metformin intolerance?

From the Guidelines

For this 75-year-old man with poorly controlled type 2 diabetes, cardiovascular disease, recent heart failure decompensation, and metformin intolerance, I recommend adding an SGLT2 inhibitor such as empagliflozin 10mg daily to his current regimen of sitagliptin 100mg and gliclazide 60mg.

Key Considerations

• SGLT2 inhibitors provide significant cardiovascular benefits, particularly in heart failure, while also improving glycemic control 1.
• Given his recent steroid use which likely worsened his glucose control, close monitoring of blood glucose is essential after discharge.
• Consider reducing the gliclazide dose if hypoglycemia occurs with the new regimen.
• A GLP-1 receptor agonist like semaglutide could be an alternative or additional option, offering both cardiovascular protection and potent glucose-lowering effects without hypoglycemia risk.

Patient Education

• The patient should be educated about hypoglycemia symptoms, sick day management, and the importance of regular follow-up within 2-4 weeks to assess treatment efficacy.

Treatment Goals

• The goal is to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes, while minimizing symptoms related to hyperglycemia and avoiding targeting an HbA1c level in patients with a life expectancy less than 10 years due to advanced age or chronic conditions 1.

Kidney Function Considerations

• SGLT2 inhibitors can be used in patients with chronic kidney disease (CKD) and estimated glomerular filtration rate (eGFR) ≥20 ml/min/1.73 m², and can be continued at lower levels of eGFR 1.

From the FDA Drug Label

The efficacy of TRADJENTA was evaluated in a 104-week, double-blind, glimepiride-controlled, non-inferiority trial in patients with type 2 diabetes mellitus with insufficient glycemic control despite metformin therapy Patients receiving glimepiride were given an initial dosage of 1 mg/day and then electively titrated over the next 12 weeks to a maximum dosage of 4 mg/day as needed to optimize glycemic control After 52 and 104 weeks, TRADJENTA and glimepiride both had reductions from baseline in A1C (52 weeks: -0.4% for TRADJENTA, -0.6% for glimepiride; 104 weeks: -0.2% for TRADJENTA, -0.4% for glimepiride) from a baseline mean of 7.7%

The patient is currently on sitagliptin (100mg) and recently increased gliclazide (from 30 to 60mg), and has a history of metformin intolerance. Considering the patient's elevated HbA1c level and history of myocardial vascular accident (MVA) and multi-cerebral artery stenosis (MCAS), the treatment goal is to optimize anti-diabetic treatment.

• The patient's current treatment regimen includes sitagliptin and gliclazide, but the label does not provide direct information on how to optimize this specific combination.
• The label does provide information on the efficacy of linagliptin in combination with metformin, but the patient has a history of metformin intolerance.
• The label also provides information on the efficacy of linagliptin compared to glimepiride as add-on therapy to metformin, but this may not be directly applicable to the patient's current situation. Given the lack of direct information on how to optimize the patient's current treatment regimen, and considering the patient's complex medical history, a conservative approach would be to consult with a healthcare professional to determine the best course of action. 2

From the Research

Optimizing Anti-Diabetic Treatment

To optimize anti-diabetic treatment for a 75-year-old man with type 2 diabetes (T2D), history of myocardial vascular accident (MVA) and multi-cerebral artery stenosis (MCAS), with elevated Hemoglobin A1c (HbA1c) level, the following considerations should be taken into account:

• The patient is currently on sitagliptin (100mg) and recently increased gliclazide (from 30 to 60mg) 3, 4.
• The patient has been hospitalized for decompensated heart failure (HF) and received prednisone for 2 days, which may affect blood glucose levels 5.
• The patient has a history of metformin intolerance, which limits treatment options 3, 4.

Treatment Options

Considering the patient's medical history and current treatment, the following options could be explored:

• Sodium-glucose co-transporter type 2 (SGLT2) inhibitors, such as dapagliflozin, canagliflozin, or empagliflozin, which have been shown to reduce HbA1c levels and have a low risk of hypoglycemia 3, 4, 6.
• Dipeptidyl peptidase 4 (DPP-4) inhibitors, such as sitagliptin, which the patient is already taking, may be continued or adjusted as needed 3, 4, 6.

Considerations for Elderly Patients

When treating elderly patients with T2D, it is essential to consider the following:

• The risk of renal impairment, orthostatic hypotension, and dehydration is higher in elderly patients, and caution is recommended when prescribing SGLT2 inhibitors 3.
• The patient's renal function and glomerular filtration rate should be monitored regularly, as SGLT2 inhibitors may not be suitable for patients with severe renal impairment 3, 4.

Monitoring and Adjustments

Regular monitoring of the patient's HbA1c levels, blood pressure, and lipid profiles is crucial to adjust treatment as needed 5.

• The patient's treatment plan should be individualized, taking into account their medical history, current medications, and response to treatment 5, 6.