From the Guidelines
For this 75-year-old patient with poorly controlled type 2 diabetes (A1c 9.2%) and moderate renal impairment (eGFR 58), I recommend optimizing the medication regimen by increasing metformin to 1000 mg BID (maximum dose), maintaining jardiance 10 mg daily, and adding a third agent such as a GLP-1 receptor agonist like semaglutide (starting at 0.25 mg weekly, titrating to 0.5-1.0 mg weekly as tolerated). The current regimen is clearly insufficient to achieve glycemic targets, as evidenced by the elevated A1c.
Key Considerations
- Metformin remains appropriate at the higher dose since the eGFR is above 45, as per the guidelines outlined in 1.
- Jardiance can be continued at the current dose with an eGFR above 45, as supported by the findings in 1.
- Adding a GLP-1 agonist provides complementary glucose-lowering effects through delayed gastric emptying, enhanced insulin secretion, and appetite suppression, with the additional benefits of weight loss and cardiovascular protection, as noted in 1.
Monitoring and Adjustments
- Regular monitoring of renal function is essential, particularly given the patient's age and existing moderate renal impairment, as emphasized in 1.
- Blood glucose monitoring should be increased initially after medication adjustments to assess efficacy and detect any hypoglycemia.
Rationale
The recommended approach is based on the most recent and highest quality evidence, prioritizing the patient's morbidity, mortality, and quality of life outcomes. The combination of metformin, jardiance, and a GLP-1 receptor agonist addresses multiple pathophysiological defects in type 2 diabetes, providing a comprehensive treatment strategy.
From the FDA Drug Label
Clinical recommendations based upon the patient's renal function include [see Dosage and Administration ( 2.1), Clinical Pharmacology ( 12. 3)] : Before initiating metformin hydrochloride tablets, obtain an estimated glomerular filtration rate (eGFR). Metformin hydrochloride tablets are contraindicated in patients with an eGFR less than 30 mL/min/1.73 m 2[see Contraindications ( 4) ]. Initiation of metformin hydrochloride tablets is not recommended in patients with eGFR between 30 to 45 mL/min/1. 73 m 2. Obtain an eGFR at least annually in all patients taking metformin hydrochloride tablets. In patients at risk for the development of renal impairment (e.g., the elderly), renal function should be assessed more frequently. In patients taking metformin hydrochloride tablets whose eGFR falls below 45 mL/min/1. 73 m 2, assess the benefit and risk of continuing therapy.
The patient's eGFR is 58, which is above the contraindicated threshold of 30 mL/min/1.73 m^2. However, since the patient's eGFR is below 60 mL/min/1.73 m^2, caution should be exercised. The medication regimen for this patient should be adjusted by:
- Assessing the benefit and risk of continuing metformin therapy at the current dose of 500 mg twice daily.
- Monitoring renal function more frequently due to the patient's age and impaired renal function.
- Considering alternative treatment options or dose adjustments if the patient's renal function declines further.
- Closely monitoring for signs of lactic acidosis, such as malaise, myalgias, abdominal pain, respiratory distress, or increased somnolence. 2
From the Research
Adjusting Medication Regimen for a 75-year-old Patient with Type 2 Diabetes Mellitus
The patient's current medication regimen consists of metformin 500 mg twice daily and Jardiance (Empagliflozin) 10 mg once daily, with an elevated Hemoglobin A1c (HbA1c) level of 9.2% and impaired renal function (eGFR of 58).
- The American Association of Clinical Endocrinologists and the American Diabetes Association recommend considering insulin administration for people with type 2 diabetes with HbA1c levels exceeding 9.0% and 10%, respectively 3.
- However, studies suggest that glucagon-like peptide-1 receptor agonists (GLP-1RAs) may offer superior benefit to insulin in reducing HbA1c levels, particularly in patients with baseline HbA1c >9% 3, 4.
- A study comparing exenatide QW and liraglutide with insulin glargine showed that GLP-1RAs led to greater reductions in HbA1c levels in patients with baseline HbA1c ≥9% 3.
- Another study found that GLP-1 agonist initiation resulted in a significant reduction of both HbA1c and weight in patients with type 2 diabetes mellitus and a baseline HbA1c ≥9% 4.
- The patient's impaired renal function (eGFR of 58) should be considered when adjusting the medication regimen, as some medications may need to be dose-adjusted or avoided in patients with renal impairment.
Potential Adjustments to the Medication Regimen
- Consider adding a GLP-1RA to the patient's current medication regimen, as they have been shown to be effective in reducing HbA1c levels in patients with type 2 diabetes mellitus and baseline HbA1c ≥9% 3, 4.
- Monitor the patient's renal function and adjust the medication regimen as needed to avoid worsening renal impairment.
- Consider consulting with a nephrologist or endocrinologist to determine the best course of treatment for the patient's impaired renal function and elevated HbA1c level.
Key Considerations
- The patient's age (75 years) and comorbidities should be taken into account when adjusting the medication regimen, as older adults may be more susceptible to adverse effects and interactions.
- Regular monitoring of the patient's HbA1c levels, renal function, and other relevant health metrics is crucial to ensure the effectiveness and safety of the adjusted medication regimen 5, 6, 7.