Medication Adjustment for Patient with Type 2 Diabetes and A1c of 8.1%
Increasing empagliflozin to 25 mg daily is the most appropriate medication adjustment for this 68-year-old female with type 2 diabetes and an A1c of 8.1%. 1
Rationale for Medication Adjustment
The patient presents with several key factors that guide our medication decision:
- A1c of 8.1% (above target)
- Current medications include metformin ER 500 mg twice daily and empagliflozin 10 mg daily
- BMI of 31.8 (obesity)
- Multiple cardiovascular risk factors (hypertension, hyperlipidemia, former smoker)
- Age 68 years
Assessment of Current Regimen
The patient's current antihyperglycemic regimen consists of:
- Metformin ER 500 mg twice daily (total 1000 mg/day)
- Empagliflozin 10 mg daily
This regimen is clearly insufficient to achieve glycemic control, as evidenced by the A1c of 8.1%.
Medication Options Analysis
Option 1: Increase Metformin ER Dose
- Current guidelines recommend metformin as first-line therapy with titration up to 2000 mg/day 2
- Increasing metformin could improve glycemic control, as shown in the GRADE study which demonstrated a 0.65% A1c reduction when increasing metformin by ≥1000 mg/day 3
- However, increasing to 500 mg four times daily (2000 mg total) may reduce adherence due to the complex dosing schedule
- Gastrointestinal side effects increase with higher doses, particularly concerning in an older adult 4
Option 2: Increase Empagliflozin Dose
- Empagliflozin can be safely increased from 10 mg to 25 mg daily 1
- FDA labeling shows that 25 mg provides additional glycemic efficacy over 10 mg 1
- SGLT2 inhibitors like empagliflozin have demonstrated cardiovascular benefits, which is important for this patient with multiple CV risk factors 2
- The higher dose provides additional weight loss benefits, which is beneficial for this obese patient (BMI 31.8) 1
Option 3: Add Pioglitazone
- Pioglitazone is associated with fluid retention and increased risk of heart failure 2
- This would be concerning given the patient's age and cardiovascular risk factors
- Weight gain is a common side effect, which would be detrimental for this obese patient
Option 4: Add Insulin Glargine
- Insulin is typically reserved for patients with more severe hyperglycemia (A1c ≥10% or blood glucose ≥300 mg/dL) 2
- Adds risk of hypoglycemia, which is particularly concerning in older adults 2
- Associated with weight gain, which would be detrimental for this obese patient
Recommendation and Implementation
Increase empagliflozin from 10 mg to 25 mg daily for the following reasons:
- Provides additional A1c-lowering efficacy without increasing hypoglycemia risk 1
- Offers cardiovascular benefits important for this patient with multiple CV risk factors 2
- Promotes weight loss, beneficial for this patient with obesity 1
- Simple dose adjustment (once daily) promotes adherence
- Well-tolerated in older adults when renal function is adequate 2
After increasing empagliflozin to 25 mg daily, if glycemic targets are still not met after 3 months, consider:
- Optimizing metformin dose to 1000 mg twice daily (if tolerated) 3
- Adding a GLP-1 receptor agonist if A1c remains elevated despite optimized doses of current medications 2
Monitoring and Follow-up
- Check A1c in 3 months to assess response to therapy
- Monitor renal function, as empagliflozin requires adequate renal function
- Counsel patient on lifestyle modifications, including diet and increasing physical activity from her current sedentary lifestyle
- Educate about symptoms of urinary tract infections and genital mycotic infections, which can occur with SGLT2 inhibitors
- Ensure patient is aware of signs/symptoms of diabetic ketoacidosis, a rare but serious side effect
This approach prioritizes cardiovascular risk reduction and weight management while improving glycemic control with minimal risk of hypoglycemia, all important considerations for this 68-year-old patient with multiple comorbidities.