Should Glyxambi (empagliflozin and linagliptin) be initiated in a patient with HbA1c 9.2% on Basaglar (insulin glargine) and Metformin, with no insurance?

Management of Uncontrolled Type 2 Diabetes with Limited Insurance Coverage

For a 55-year-old female with an HbA1c of 9.2% on Basaglar 44 units daily and Metformin 1000mg twice daily who has no insurance, Glyxambi (empagliflozin/linagliptin) should not be initiated due to cost considerations; instead, adding a sulfonylurea would be more appropriate and affordable.

Current Clinical Situation Assessment

The patient presents with:

• HbA1c of 9.2% (indicating poor glycemic control)
• Current therapy: Basaglar (insulin glargine) 44 units daily and Metformin 1000mg twice daily
• No insurance coverage (significant financial constraint)

Treatment Decision Algorithm

Step 1: Evaluate Current Therapy and Need for Intensification

• HbA1c >9.0% indicates inadequate glycemic control requiring therapy intensification 1
• Current regimen includes basal insulin and metformin, which is appropriate but insufficient

Step 2: Consider Treatment Options Based on Guidelines

According to ADA/EASD guidelines:

• For patients with HbA1c ≥9.0%, additional medication is recommended 1
• When cost is a significant factor, less expensive agents should be chosen 1
• Options for add-on therapy to metformin and basal insulin include:
  • Sulfonylurea (low cost)
  • DPP-4 inhibitor (high cost)
  • GLP-1 receptor agonist (high cost)
  • SGLT2 inhibitor (high cost)

Step 3: Evaluate Glyxambi as an Option

Glyxambi combines:

• Empagliflozin (SGLT2 inhibitor)
• Linagliptin (DPP-4 inhibitor)

While clinical evidence shows Glyxambi is effective:

• Combination of empagliflozin/linagliptin provides significant HbA1c reduction of 1.08-1.24% 2, 3
• When added to basal insulin, empagliflozin alone can reduce HbA1c by 0.6-0.7% 4

However, critical limitations exist:

• Glyxambi is an expensive branded medication
• Patient has no insurance coverage
• Guidelines explicitly state: "For resource-limited settings, less expensive agents should be chosen" 1

Step 4: Recommend Appropriate Alternative

For patients without insurance:

• Add a sulfonylurea (such as glipizide or glimepiride)
  • Low cost (often $4-10/month at discount pharmacies)
  • Effective HbA1c reduction (0.5-1.5%)
  • Can be used safely with basal insulin with appropriate monitoring
  • Explicitly recommended in ADA/EASD algorithm for cost-constrained situations 1

Implementation Plan

1. Medication Addition:

   • Start with a sulfonylurea (e.g., glimepiride 2mg daily or glipizide 5mg daily)
   • Titrate dose based on fasting and pre-meal glucose levels

2. Insulin Management:

   • Continue Basaglar 44 units daily
   • Monitor for hypoglycemia, especially when adding sulfonylurea
   • Consider reducing insulin dose by 10-20% when starting sulfonylurea if fasting glucose is <130 mg/dL

3. Monitoring:

   • Blood glucose monitoring at least once daily (preferably fasting)
   • Return for follow-up in 2-4 weeks to assess response
   • Check HbA1c in 3 months

Important Considerations and Pitfalls

• Hypoglycemia risk: The combination of sulfonylurea and insulin increases hypoglycemia risk; patient education on recognition and management is essential
• Cost-saving strategies: Explore patient assistance programs for medications and supplies
• Long-term planning: Consider working with social services to explore insurance options (Medicaid, ACA marketplace)
• Alternative future options: If insurance becomes available, reassess for more optimal therapy with cardiovascular benefits (GLP-1 RA or SGLT2 inhibitor) 1, 5

While Glyxambi would provide excellent glycemic control with low hypoglycemia risk 2, 3, the financial burden would likely lead to medication non-adherence, which would worsen outcomes. The recommended approach prioritizes affordability while still addressing the clinical need for improved glycemic control.