What is the best course of action to improve glycemic control in a patient with HbA1c of 10.8% on Jardiance (Empagliflozin) 25 mg and Ozempic (Semaglutide) 2 mg?

From the Guidelines

For a patient with an HbA1c of 10.8% despite being on Jardiance (empagliflozin 25 mg) and Ozempic (semaglutide 2 mg), the best course of action would be to initiate insulin therapy, specifically basal insulin, to address the severe hyperglycemia. The patient's current HbA1c level indicates a significant gap in glycemic control, and the addition of insulin is necessary to supplement the body's insufficient insulin production, as the current medications, although potent, have not achieved adequate control. Key considerations in managing this patient include:

• The importance of lifestyle interventions, including exercise, dietary changes, and weight loss, as emphasized by the American College of Physicians guidance statement update 1.
• The potential benefits and harms of more intensive glycemic control, which may require a long time to manifest and should be considered in the context of the patient's life expectancy and preferences.
• The need to balance glycemic control with other priorities, such as blood pressure control, lipid management, and smoking cessation, which may take precedence in preventing macrovascular complications. Given the patient's high HbA1c level, initiating basal insulin therapy, such as insulin glargine or insulin degludec, at a reasonable starting dose of 10 units once daily, with adjustments based on fasting blood glucose levels, is a practical approach. This recommendation is supported by the principle that any benefit of more intensive glycemic control likely requires a long time to manifest, and thus, more stringent targets may be appropriate for patients with a long life expectancy 1. The patient should continue both Jardiance and Ozempic alongside insulin therapy, as these medications provide complementary mechanisms of action to improve glycemic control through multiple pathways. Blood glucose monitoring should be initiated at least once daily, and the patient should be educated about hypoglycemia symptoms and management to ensure safe and effective insulin therapy.

From the FDA Drug Label

At Week 24, initial therapy of JARDIANCE in combination with metformin provided statistically significant reductions in HbA1c (p-value <0. 01) compared to the individual components At Week 24, treatment with JARDIANCE 10 mg or 25 mg daily provided statistically significant reductions in HbA1c (p-value <0. 0001), fasting plasma glucose (FPG), and body weight compared with placebo The best course of action to improve glycemic control in a patient with HbA1c of 10.8% on Jardiance (Empagliflozin) 25 mg and Ozempic (Semaglutide) 2 mg is to consider optimizing the current regimen or adding another agent to the treatment plan, as the current HbA1c level is above the target range. However, the provided drug labels do not directly address the specific combination of Jardiance and Ozempic.

• Key considerations:
  • The patient is already on a high dose of Jardiance (25 mg) and Ozempic (2 mg), which may indicate a need for additional or alternative therapies to achieve better glycemic control.
  • The drug labels provide evidence for the efficacy of Jardiance in combination with metformin, sulfonylurea, pioglitazone, linagliptin, and insulin, but do not specifically address the combination with Ozempic.
  • The patient's HbA1c level of 10.8% suggests a need for intensification of therapy, which may involve adding another medication or adjusting the current doses.
  • It is essential to consider the patient's individual factors, such as renal function, cardiovascular risk, and potential side effects, when selecting the next course of action.
  • Consultation with a healthcare professional is necessary to determine the best approach for this patient. 2 2 2

From the Research

Patient's Current Medication and Glycemic Control

• The patient is currently taking Jardiance (Empagliflozin) 25 mg and Ozempic (Semaglutide) 2 mg.
• The patient's HbA1c level is 10.8%, indicating sub-optimal glycemic control.

Considerations for Improving Glycemic Control

• According to the study 3, for patients with HbA1c > 9%, insulin administration may be considered, but the addition of other agents such as GLP-1 receptor agonists (e.g., semaglutide) or SGLT2 inhibitors (e.g., empagliflozin) may also be effective.
• The study 4 suggests that a combination of exenatide (a GLP-1 receptor agonist) and pioglitazone may be an effective and safe therapeutic option for patients with poorly controlled type 2 diabetes and very high HbA1c (> 10%).
• The study 5 demonstrates that semaglutide, a GLP-1 receptor agonist, is effective in reducing HbA1c and body weight, with fewer hypoglycemic episodes, compared to insulin glargine.
• The study 6 indicates that the combination of an SGLT2 inhibitor (e.g., empagliflozin) with metformin is more effective in reducing HbA1c and body weight compared to metformin monotherapy.
• The study 7 shows that empagliflozin added to metformin and sulfonylurea therapy can significantly improve glycemic control, reduce body weight, and lower blood pressure.

Potential Next Steps

• Consider optimizing the patient's current medication regimen, potentially by adjusting the dose of semaglutide or adding another agent, such as a sulfonylurea or pioglitazone, to improve glycemic control.
• Monitor the patient's response to the current medication regimen and adjust as needed to achieve optimal glycemic control.
• Consider referring the patient to a specialist, such as an endocrinologist, for further evaluation and management of their diabetes.