From the Guidelines
For a patient with diabetes on metformin with an elevated HbA1c level of 8.1, the next oral medication to consider adding is typically a sodium-glucose cotransporter-2 (SGLT2) inhibitor or a glucagon-like peptide-1 (GLP-1) receptor agonist, as recommended by the most recent guidelines 1. The choice of medication added to metformin is based on the clinical characteristics of the patient and their preferences, including the presence of established ASCVD or indicators of high ASCVD risk, heart failure, CKD, other comorbidities, and risk for specific adverse drug effects, as well as safety, tolerability, and cost 1. Some key points to consider when adding a new medication to metformin include:
- SGLT2 inhibitors like empagliflozin (Jardiance), dapagliflozin (Farxiga), or canagliflozin (Invokana) are often preferred due to their cardiovascular and renal benefits 1.
- The typical starting dose for empagliflozin is 10mg once daily, which can be increased to 25mg if needed.
- These medications work by preventing glucose reabsorption in the kidneys, causing excess glucose to be excreted in urine.
- They offer the advantages of modest weight loss, blood pressure reduction, and have shown to reduce heart failure hospitalizations and progression of kidney disease.
- Common side effects include genital yeast infections and urinary tract infections.
- Patients should be advised to maintain adequate hydration and practice good genital hygiene.
- SGLT2 inhibitors should be used cautiously in patients with reduced kidney function and are not recommended when eGFR falls below 30 ml/min/1.73m². Alternative options include GLP-1 receptor agonists, DPP-4 inhibitors, sulfonylureas, or thiazolidinediones, depending on patient-specific factors such as cardiovascular risk, weight concerns, hypoglycemia risk, and cost considerations 1. It's also important to note that treatment intensification, deintensification, or modification, as appropriate, for people not meeting individualized treatment goals should not be delayed, and incorporation of high-glycemic-efficacy therapies or therapies for cardiovascular and kidney disease risk reduction may reduce the need for agents that increase the risks of hypoglycemia and weight gain or are less well tolerated 1.
From the Research
Next Oral Medication for Patient with Diabetes on Metformin
The patient has an elevated Hemoglobin A1c (HbA1c) level of 8.1% while on metformin. Considering the next oral medication, the following options can be considered:
- DPP-4 inhibitors: These can be added to metformin, especially in patients at risk of hypoglycemia 2. They are weight neutral and have a low incidence of hypoglycemia 3.
- SGLT2 inhibitors: These can also be added to metformin, particularly in obese patients or those with hypertension, hyperuricaemia, or a history of cardiovascular disease 2.
- GLP-1 agonists: These can be considered as an alternative to insulin, especially in patients with HbA1c levels above 9% 4. They have been shown to have a superior HbA1c-lowering effect compared to insulin glargine in some studies 4.
- Sulfonylurea: This can be added to metformin, but it may increase the risk of hypoglycemia 5.
- Thiazolidinediones: These can be considered in combination with a GLP-1 agonist, especially in patients with HbA1c levels above 10% 4.
Key Considerations
When choosing the next oral medication, consider the following factors:
- Patient characteristics, such as obesity, renal impairment, or history of cardiovascular disease
- Risk of hypoglycemia and weight gain
- Efficacy of the medication in reducing HbA1c levels
- Potential benefits on beta cell function and cardiovascular outcomes
Potential Combinations
Some potential combinations of medications that can be considered are: