What adjustments should be made to the medication regimen of a geriatric patient with a history of type 2 diabetes mellitus, currently taking metformin (Metformin) 500 mg twice daily (BID), Jardiance (Empagliflozin) 10 mg once daily (QD), with an elevated Hemoglobin A1c (HbA1c) level?

From the Guidelines

For this geriatric patient with poorly controlled type 2 diabetes on metformin 500 mg BID and Jardiance 10 mg daily, I recommend optimizing the current regimen by increasing metformin to 1000 mg BID (maximum effective dose) if tolerated, maintaining Jardiance at 10 mg daily, and adding a third agent such as a GLP-1 receptor agonist like semaglutide (Ozempic) starting at 0.25 mg weekly for 4 weeks, then increasing to 0.5 mg weekly. The patient's current regimen is insufficient to achieve the target A1c of less than 7%. Metformin works by decreasing hepatic glucose production and improving insulin sensitivity, while Jardiance (empagliflozin) promotes urinary glucose excretion. Adding a GLP-1 agonist would provide complementary benefits through increased insulin secretion, decreased glucagon, delayed gastric emptying, and appetite suppression. This combination addresses multiple pathophysiological defects in type 2 diabetes. Before implementing these changes, assess renal function, as both metformin and Jardiance require dose adjustments with reduced kidney function, as noted in the 2022 consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO) 1. Also evaluate for hypoglycemia risk, gastrointestinal tolerance, and ensure the patient understands proper administration of injectable therapy if a GLP-1 agonist is added. Key considerations for the patient's medication regimen include:

• Monitoring eGFR every 3 to 6 months in those at risk for decline in kidney function, as recommended in the 2025 standards of care in diabetes 1
• Assessing the risk of lactic acidosis with metformin, particularly in patients with hypoperfusion, hypoxemia, impaired hepatic function, or heart failure
• Evaluating the patient's response to the medication regimen and adjusting as needed to achieve the target A1c level Schedule follow-up in 3 months to reassess A1c and adjust therapy as needed, taking into account the patient's individual response to the medication regimen and any potential side effects or complications. The most recent guidelines from 2023 support the use of GLP-1 RAs as the preferred option for individuals requiring the potency of an injectable therapy for glucose control 1.

From the FDA Drug Label

2 DOSAGE AND ADMINISTRATION

2.1 Adult Dosage Metformin Hydrochloride Tablets The recommended starting dose of metformin hydrochloride tablets are 500 mg orally twice a day or 850 mg once a day, given with meals. Increase the dose in increments of 500 mg weekly or 850 mg every 2 weeks on the basis of glycemic control and tolerability, up to a maximum dose of 2550 mg per day, given in divided doses.

The patient is currently taking metformin 500 mg twice daily. To adjust the medication regimen for the geriatric patient with an elevated HbA1c level, consider increasing the dose of metformin in increments of 500 mg weekly, up to a maximum dose of 2550 mg per day, given in divided doses, as long as the patient's renal function and tolerability allow it 2. Key considerations:

• Assess renal function prior to initiation or adjustment of metformin dose.
• Monitor for signs of hypoglycemia or other adverse effects.
• Consider the patient's overall health status and ability to tolerate increased doses of metformin. No direct information is provided about adjusting the dose of Jardiance (Empagliflozin) in this context 2.

From the Research

Adjustments to Medication Regimen

To address the elevated Hemoglobin A1c (HbA1c) level in a geriatric patient with type 2 diabetes mellitus, currently taking metformin 500 mg twice daily (BID) and Jardiance (Empagliflozin) 10 mg once daily (QD), several factors should be considered:

• The patient's age, as older age is significantly associated with higher sulfonylurea prescription and lower prescribing of metformin, SGLT2 inhibitors, and GLP1 receptor agonists 3
• The patient's baseline body mass index (BMI), as higher baseline BMI is associated with higher metformin, SGLT2 inhibitors, and GLP1 receptor agonists prescriptions 3
• The patient's baseline HbA1c level, as higher baseline HbA1c is associated with lower metformin prescription and higher insulin prescriptions 3
• The presence of kidney-related problems, as this is associated with lower metformin prescription and higher DPP4 inhibitors prescriptions 3

Potential Adjustments

Based on the evidence, potential adjustments to the medication regimen could include:

• Intensifying the current metformin and Empagliflozin regimen, as metformin is proven to reduce all-cause mortality and cardiovascular events in overweight patients with diabetes 4
• Adding a sulfonylurea, as this is commonly prescribed for patients with higher baseline HbA1c levels 3
• Adding a GLP1 receptor agonist, as this has been shown to be effective in reducing HbA1c levels, especially in patients with higher baseline HbA1c levels 5, 6
• Considering insulin therapy, as this is recommended for patients with type 2 diabetes mellitus and an initial A1C level greater than 9 percent, or if diabetes is uncontrolled despite optimal oral glycemic therapy 4

Importance of Medication Adherence

It is essential to note that medication adherence plays a significant role in achieving glycemic control, and poor adherence can lead to clinical inertia 7. Therefore, any adjustments to the medication regimen should take into account the patient's ability to adhere to the treatment plan.

Considerations for Geriatric Patients

When making adjustments to the medication regimen for a geriatric patient, it is crucial to consider the potential risks and benefits of each medication, as well as the patient's overall health status, including the presence of any comorbidities or kidney-related problems 3, 4.