What to do in a patient with type 2 diabetes mellitus (DM2) on linagliptin (Tradjenta) with hyperglycemia?

From the Guidelines

For a patient with type 2 diabetes mellitus (DM2) on linagliptin (Tradjenta) experiencing hyperglycemia with a blood sugar of 262, intensification of therapy is needed to prevent complications and improve quality of life. First, verify medication adherence and assess for any contributing factors like illness, stress, or dietary changes. If the patient is only on linagliptin, consider adding metformin (starting at 500 mg once or twice daily, gradually increasing to 1000 mg twice daily as tolerated) if not contraindicated, as metformin is the preferred initial pharmacologic agent for type 2 diabetes management 1. If metformin is already part of the regimen, adding a sodium-glucose cotransporter-2 (SGLT2) inhibitor like empagliflozin (10-25 mg daily) or a glucagon-like peptide-1 (GLP-1) receptor agonist such as semaglutide (starting at 0.25 mg weekly, increasing to 0.5-1 mg weekly) would be appropriate, based on the patient's disease characteristics and preferences 1. For patients with persistent hyperglycemia despite these measures, basal insulin (like insulin glargine 10 units at bedtime, titrated based on fasting glucose) may be necessary, as insulin therapy should not be delayed in patients not achieving glycemic goals 1. Lifestyle modifications including dietary changes, increased physical activity, and weight management remain essential components of treatment, aiming for at least 150 minutes of moderate-intensity aerobic activity per week and reduced sedentary time 1. This stepped approach addresses the progressive nature of type 2 diabetes, where beta-cell function gradually declines over time, necessitating additional medications with complementary mechanisms of action to achieve glycemic targets and reduce the risk of cardiovascular events and death 1.

From the FDA Drug Label

TRADJENTA is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

The patient has a blood sugar of 262, which is above the target range. Since the patient is already on linagliptin, the first step would be to:

• Assess adherence to the current medication regimen and diet/exercise plan
• Evaluate for any potential causes of hyperglycemia, such as infection, stress, or changes in diet or physical activity
• Consider adjusting the treatment plan, which may include increasing the dose of linagliptin (if not already at the maximum dose), adding another antihyperglycemic agent, or initiating insulin therapy, under the guidance of a healthcare professional 2.
• Monitor blood glucose levels closely and adjust the treatment plan as needed to achieve target blood glucose levels.

From the Research

Management of Hyperglycemia in Type 2 Diabetes Mellitus

• In a patient with type 2 diabetes mellitus (DM2) on linagliptin (Tradjenta) with a blood sugar level of 262 mg/dL, the primary goal is to achieve adequate glycemic control while minimizing the risk of hypoglycemia and other adverse effects 3, 4.
• Linagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor, has been shown to improve glycemic control in patients with type 2 diabetes by increasing incretin levels, lowering glucagon, and reducing blood glucose levels in a glucose-dependent manner 4.
• The patient's current blood sugar level of 262 mg/dL indicates hyperglycemia, which may require adjustment of their treatment regimen to achieve better glycemic control.

Treatment Options

• Continuing linagliptin therapy, as it has been shown to be effective in improving glycemic control in patients with type 2 diabetes 3, 4.
• Considering the addition of other anti-diabetic medications, such as metformin or a sulfonylurea, to the patient's treatment regimen to achieve better glycemic control 3.
• Monitoring the patient's blood sugar levels regularly to assess the effectiveness of their treatment regimen and make adjustments as needed.

Safety and Efficacy

• Linagliptin has been shown to have a good safety profile, with a low incidence of hypoglycemia and no association with weight gain 3, 5.
• The patient's asymptomatic status and lack of reported adverse effects suggest that linagliptin is well-tolerated, but ongoing monitoring is necessary to ensure the patient's safety and efficacy of treatment 6, 5.

Dosing Regimen

• The standard dosing regimen for linagliptin is 5 mg once daily, but some studies have explored the use of alternate-day dosing in patients with stable glycemic control 7.
• However, the efficacy and safety of alternate-day dosing in patients with hyperglycemia, such as the patient in question, are not well established, and further studies are needed to determine the optimal dosing regimen for these patients.