Is a regimen of pioglitazone (TZD) 15 mg, empagliflozin (SGLT2 inhibitor) 20 mg, and gliclazide (sulfonylurea) 60 mg an accepted treatment approach for a female patient with type 2 diabetes mellitus (DMT2)?

From the Guidelines

The combination of pioglitazone 15 mg, empagliflozin 20 mg, and gliclazide 60 mg can be an acceptable treatment approach for a female patient with type 2 diabetes mellitus, particularly when glycemic control is not achieved with one or two agents alone. This triple therapy targets different pathophysiological mechanisms of diabetes: pioglitazone improves insulin sensitivity, empagliflozin promotes urinary glucose excretion, and gliclazide stimulates insulin secretion. However, this combination requires careful monitoring for potential side effects. Pioglitazone may cause fluid retention, weight gain, and increased risk of fractures in women 1. Empagliflozin can lead to genital infections and urinary tract infections, which are more common in females 1. Gliclazide carries a risk of hypoglycemia, especially when combined with other glucose-lowering medications 1. Regular monitoring of blood glucose levels, renal function, and potential side effects is essential. Additionally, this regimen should be part of a comprehensive approach that includes lifestyle modifications such as diet and exercise. Dose adjustments may be necessary based on the patient's response, tolerability, and kidney function 1. If the patient is of reproductive age, appropriate contraception should be discussed as these medications have not been extensively studied in pregnancy. It is also important to note that the recommended dose of empagliflozin is 10 mg daily for improving glycemic control in adults with type 2 diabetes, as stated in the 2020 expert consensus decision pathway on novel therapies for cardiovascular risk reduction in patients with type 2 diabetes 1. Therefore, the current dose of 20 mg may need to be adjusted based on the patient's response and tolerability. Overall, the decision to use this combination therapy should be individualized and based on the patient's specific needs and medical history.

From the Research

Treatment Approach for Type 2 Diabetes Mellitus

The regimen of pioglitazone (TZD) 15 mg, empagliflozin (SGLT2 inhibitor) 20 mg, and gliclazide (sulfonylurea) 60 mg for a female patient with type 2 diabetes mellitus (DMT2) can be evaluated based on available evidence:

• Pioglitazone has been shown to improve glycemic control and serum lipid profiles in patients with type 2 diabetes mellitus, with a study indicating its effectiveness as monotherapy or in combination with other drugs 2.
• Empagliflozin has been found to reduce the risk of cardiovascular events and improve glycemic control in patients with type 2 diabetes mellitus, with studies demonstrating its safety and efficacy as monotherapy or in combination with other treatments 3, 4.
• The combination of an SGLT2 inhibitor (such as empagliflozin) with a thiazolidinedione (such as pioglitazone) has been studied, showing that the addition of an SGLT2 inhibitor can further reduce HbA(1c) levels and mitigate weight gain associated with thiazolidinedione therapy 5.
• The use of sulfonylureas (such as gliclazide) in combination with other diabetes medications, including pioglitazone and empagliflozin, is a common practice, although it may increase the risk of hypoglycemia 6, 4.

Key Considerations

When evaluating the acceptability of this treatment regimen, consider the following:

• The patient's individual characteristics, such as renal function and risk of cardiovascular events, should be taken into account when selecting a treatment approach 3, 4.
• The potential benefits of improved glycemic control and reduced cardiovascular risk should be weighed against the potential risks of adverse events, such as hypoglycemia, genital mycotic infections, and volume depletion 3, 5, 4.
• Regular monitoring of the patient's response to treatment and adjustment of the regimen as needed is crucial to ensure optimal outcomes 6, 2.