Can bexagliflozin be prescribed for a patient with type 2 diabetes, hyperlipidemia, hypertension, microalbuminuria, and diabetic retinopathy on metformin and insulin detemir with an HbA1c of 8.6%?

Bexagliflozin for Type 2 Diabetes with Complications

Bexagliflozin is an appropriate addition to the treatment regimen for your 38-year-old male patient with type 2 diabetes, hyperlipidemia, hypertension, microalbuminuria, and diabetic retinopathy who has an uncontrolled A1C of 8.6% on metformin and insulin detemir. 1, 2

Rationale for Adding Bexagliflozin

• SGLT2 inhibitors like bexagliflozin have demonstrated effectiveness in reducing A1C levels, particularly in patients with diabetes and chronic kidney disease (CKD) with microalbuminuria 1
• Bexagliflozin has been shown to reduce A1C by 0.37% compared to placebo in patients with type 2 diabetes and CKD 1
• For patients with an A1C of 8.6% (well above the target of <7%), intensification of therapy beyond metformin and basal insulin is indicated 3
• The presence of microalbuminuria and diabetic retinopathy indicates microvascular complications that would benefit from improved glycemic control and the specific renal benefits of an SGLT2 inhibitor 4, 5

Benefits Beyond Glycemic Control

• Bexagliflozin provides several additional benefits particularly relevant to this patient's comorbidities:
  • Reduction in albuminuria (20.1% decrease in geometric mean ratio) 1
  • Decrease in systolic blood pressure (3.8 mmHg reduction) 1
  • Weight loss (1.61 kg reduction) 1
  • These effects address the patient's hypertension and may help with overall cardiovascular risk reduction 2

Efficacy in Patients with Renal Impairment

• Bexagliflozin maintains effectiveness even in patients with reduced renal function (CKD stages 3a and 3b) 1
• In patients with CKD stage 3a (eGFR 45-<60 mL/min/1.73m²), bexagliflozin reduced A1C by 0.31% 1
• In patients with CKD stage 3b (eGFR 30-<45 mL/min/1.73m²), bexagliflozin reduced A1C by 0.43% 1
• This is particularly important for patients with microalbuminuria who may have or develop declining renal function 4

Safety Considerations

• The most common adverse events associated with bexagliflozin are urinary tract infections and genital mycotic infections 1
• Otherwise, the frequency of adverse events is comparable to placebo 1
• Recent comparative data shows that bexagliflozin has a similar safety profile to other SGLT2 inhibitors like dapagliflozin 6
• Monitor renal function periodically as is standard practice with SGLT2 inhibitors 1

Treatment Algorithm for This Patient

1. Add bexagliflozin 20mg daily to the current regimen of metformin and insulin detemir 1, 6
2. Target A1C of <7% as recommended for most adults with type 2 diabetes 3
3. Continue to monitor:
   • A1C every 3 months 3
   • Renal function and albuminuria 1
   • Blood pressure and weight 1
4. If glycemic targets are still not met after adding bexagliflozin, consider:
   • Adjusting insulin dosing 3
   • Adding a GLP-1 receptor agonist 3

Clinical Pearls and Caveats

• The combination of microalbuminuria and diabetic retinopathy indicates significant microvascular disease, making aggressive treatment important 5
• SGLT2 inhibitors like bexagliflozin may provide cardio-renal protection beyond their glucose-lowering effects, which is particularly beneficial for this patient with multiple risk factors 2
• Ensure proper hydration and genital hygiene to minimize risk of urinary tract infections and genital mycotic infections 1
• Educate the patient about potential side effects and the importance of maintaining adequate fluid intake 1