From the Research
For a patient with severe hyperglycemia (A1c 13.2%) who refuses insulin, consider initiating a combination of oral antidiabetic medications while continuing to educate about insulin benefits. Start with metformin 500mg twice daily, increasing to 1000mg twice daily as tolerated, plus a GLP-1 receptor agonist like semaglutide (starting at 0.25mg weekly, increasing to 1mg weekly) 1. Add an SGLT-2 inhibitor such as empagliflozin 10mg daily if no contraindications exist 2. For immediate glucose control, consider short-term use of sulfonylureas like glipizide 5mg daily. Schedule frequent follow-ups every 2-4 weeks initially to monitor progress, adjust medications, and continue insulin discussions. This approach leverages multiple mechanisms to lower glucose: metformin reduces hepatic glucose production, GLP-1 agonists enhance insulin secretion and reduce glucagon, while SGLT-2 inhibitors promote urinary glucose excretion. However, be transparent that this regimen may not achieve target control given the very high A1c, and insulin remains the most effective option. Monitor for medication side effects and assess kidney function, hydration status, and potential diabetic ketoacidosis, especially when initiating SGLT-2 inhibitors 2.
Some key points to consider:
- The combination of GLP-1 receptor agonists and SGLT-2 inhibitors has been shown to have beneficial effects on glycemic control, body weight, and cardiovascular risk factors 1.
- The use of these medications may reduce the risk of cardiovascular disease, which is a major concern for patients with type 2 diabetes 2.
- It is essential to continue educating the patient about the benefits of insulin therapy and to reassess their willingness to start insulin at future follow-up appointments.
- Regular monitoring of the patient's condition and adjustment of the treatment plan as needed is crucial to achieve optimal glycemic control and minimize the risk of complications. The most recent and highest quality study 2 supports the use of GLP-1 receptor agonists and SGLT-2 inhibitors in the treatment of type 2 diabetes, and this approach should be considered for patients who refuse insulin therapy.