Should the treatment plan be adjusted for an 82-year-old patient with an increased HbA1c from 6.6 to 7.4, currently on metformin 1000mg once a day and Farxiga 10mg daily?

Managing Increased HbA1c in an 82-Year-Old Patient

For an 82-year-old patient with an HbA1c increase from 6.6% to 7.4% on metformin 1000mg daily and Farxiga 10mg daily, no medication changes are needed as this A1c level is appropriate for this age group and current therapy is adequate. 1

Assessment of Current Glycemic Control

The patient's current A1c of 7.4% is actually within the recommended target range for older adults. According to the American Diabetes Association's 2023 Standards of Care:

• For healthy older adults with few comorbidities, an A1c target of <7.0-7.5% is reasonable 1
• For complex/intermediate health status older adults (those with multiple chronic illnesses), an A1c target of <8.0% is appropriate 1
• For very complex/poor health older adults, avoiding symptomatic hyperglycemia is the primary goal rather than targeting a specific A1c 1

At 82 years old, this patient likely falls into the complex/intermediate health status category, making the current A1c of 7.4% acceptable and within target range.

Current Medication Assessment

The patient is currently on:

• Metformin 1000mg daily (appropriate first-line therapy)
• Farxiga (dapagliflozin) 10mg daily (appropriate second-line agent)

This combination is reasonable because:

1. Metformin remains the first-line agent for type 2 diabetes management 2
2. SGLT2 inhibitors like Farxiga have demonstrated efficacy as add-on therapy to metformin 3, 4
3. The patient reports taking medications as prescribed

Considerations for Older Adults

For patients aged 80+ years, several factors support maintaining the current regimen:

• The American College of Physicians recommends an A1c target of 7-8% for most older adults 1
• Avoiding hypoglycemia is a priority in older adults, and the current regimen has a low risk of hypoglycemia 1
• Treatment deintensification should be considered for older adults with A1c <6.5%, not intensification for those with A1c in the appropriate range 1

Potential Risks of Intensifying Therapy

Adding additional medications or increasing doses could lead to:

• Increased risk of hypoglycemia
• Polypharmacy concerns
• Increased medication burden
• Greater risk of side effects
• Minimal clinical benefit given the patient's age and current A1c

Monitoring Recommendations

While maintaining the current regimen:

1. Continue regular A1c monitoring every 3-6 months
2. Monitor for symptoms of hyperglycemia or hypoglycemia
3. Assess medication adherence at each visit
4. Consider lifestyle modifications if appropriate for the patient's functional status

When to Consider Treatment Changes

Treatment intensification would only be warranted if:

1. A1c increases significantly above 8.0%
2. The patient develops symptoms of hyperglycemia
3. There is evidence of complications related to poor glycemic control

Conclusion

Based on current guidelines for diabetes management in older adults, the patient's A1c of 7.4% is within an appropriate target range for an 82-year-old. The current regimen of metformin and Farxiga is appropriate, and no medication changes are needed at this time.