What alternative treatment options are available for a 72-year-old patient with type 2 diabetes, hyperglycemia (Blood Glucose Level of 11.8), and an HbA1c (Hemoglobin A1c) level of 6.8, who is non-compliant with metformin and sitagliptin?

Treatment Options for a 72-Year-Old with Type 2 Diabetes and Medication Non-Compliance

For a 72-year-old patient with type 2 diabetes who has a blood glucose level of 11.8 mmol/L and HbA1c of 6.8% but is non-compliant with metformin and sitagliptin, the most appropriate approach is to initiate a sodium-glucose cotransporter-2 (SGLT2) inhibitor as an alternative therapy. 1

Assessment of Current Situation

• The patient's HbA1c of 6.8% indicates relatively good overall glycemic control despite the elevated blood glucose level of 11.8 mmol/L, suggesting fluctuating glucose levels rather than consistently poor control 1
• Non-compliance with metformin and sitagliptin may be due to side effects, dosing complexity, or other barriers that should be identified 2
• At age 72, medication selection must consider age-related factors including risk of hypoglycemia, comorbidities, and simplified regimens to improve adherence 1

Recommended Treatment Approach

First-Line Option: SGLT2 Inhibitor

• SGLT2 inhibitors are preferred agents for elderly patients with type 2 diabetes due to:
  • Once-daily dosing that improves adherence 1
  • Low risk of hypoglycemia compared to sulfonylureas or insulin 1
  • Additional cardiovascular and renal benefits beyond glucose control 1
  • Weight reduction effects that may benefit overall metabolic health 1

Alternative Options (if SGLT2 inhibitor is contraindicated or not tolerated):

1. GLP-1 Receptor Agonist:

   • Provides effective glucose control with low hypoglycemia risk 1
   • Available in once-weekly formulations that may improve adherence 1
   • Offers cardiovascular benefits and weight reduction 1
   • Consider if patient can manage injectable therapy 1

2. DPP-4 Inhibitor (different from sitagliptin):

   • Once-daily oral medication with good tolerability 1
   • Weight-neutral with low hypoglycemia risk 1
   • Consider if SGLT2 inhibitors and GLP-1 RAs are contraindicated 1
   • Avoid in patients with heart failure (except sitagliptin) 1

3. Basal Insulin:

   • Consider if HbA1c rises significantly or if hyperglycemia worsens 3
   • Start with 10 units or 0.1-0.2 units/kg/day 1, 3
   • Requires patient education on administration and hypoglycemia management 3

Addressing Medication Non-Compliance

• Investigate specific reasons for non-compliance with previous medications:

  • For metformin: Consider gastrointestinal side effects, tablet size, or dosing frequency 2
  • For sitagliptin: Assess cost concerns or perceived lack of efficacy 4

• Consider alternative formulations to improve adherence:

  • Extended-release metformin if GI side effects were the main barrier 5
  • Liquid metformin if swallowing difficulties were present 2
  • Fixed-dose combination tablets if pill burden was an issue 6

Monitoring and Follow-Up

• Schedule follow-up within 1-3 months to assess response to new therapy 1
• Monitor for medication-specific side effects (e.g., genital mycotic infections with SGLT2 inhibitors) 1
• Reassess HbA1c every 3-6 months to evaluate long-term glycemic control 1
• Consider simplified treatment regimens and shared decision-making to improve adherence 2

Important Considerations and Cautions

• Avoid thiazolidinediones (TZDs) in elderly patients due to increased risk of heart failure, fluid retention, and fractures 1
• Use sulfonylureas with caution due to higher hypoglycemia risk in elderly patients 1
• If insulin is required, ensure proper education on administration and hypoglycemia management 3
• Consider the patient's renal function when selecting medications, particularly for metformin and SGLT2 inhibitors 7