Can an 87-year-old patient's medication regimen be decreased with an A1C level of 6.0, while taking nateglinide, insulin glargine, and Jardiance (empagliflozin)?

Medication Reduction for 87-Year-Old with A1C of 6.0%

Yes, you should decrease medications for this 87-year-old patient with an A1C of 6.0% who is currently on nateglinide, insulin glargine, and empagliflozin (Jardiance). 1

Rationale for Medication Reduction

• For very complex/poor health or older adults (>75 years), an A1C target of <8.0% is generally appropriate, with a focus on avoiding hypoglycemia and symptomatic hyperglycemia rather than tight control 1
• An A1C of 6.0% in an 87-year-old patient indicates potential overtreatment, which increases risk of hypoglycemia without providing additional benefits for mortality or quality of life 1
• The current regimen includes three medications with overlapping effects and different hypoglycemia risks:
  • Nateglinide (insulin secretagogue) - moderate hypoglycemia risk 1, 2
  • Insulin glargine - highest hypoglycemia risk 1
  • Empagliflozin (SGLT2 inhibitor) - lower hypoglycemia risk but can increase risk when combined with insulin 3, 4

Recommended Approach to Medication Reduction

Step 1: Assess Hypoglycemia Risk

• Evaluate for any history of hypoglycemic episodes 1
• Check for inconsistent eating patterns which would increase risk with nateglinide 1
• Review cognitive and functional status to determine ability to manage complex medication regimens 1

Step 2: Medication Reduction Strategy

1. First consider reducing or discontinuing nateglinide:

   • Nateglinide is generally not preferred in older adults due to hypoglycemia risk 1, 2
   • Studies show limited benefit when combined with insulin glargine 5

2. If further reduction needed, adjust insulin glargine:

   • Reduce insulin dose by 10-20% initially 1
   • Monitor blood glucose for 1-2 weeks before further adjustments
   • Target higher fasting glucose range (100-180 mg/dL) for this age group 1

3. Consider maintaining empagliflozin if tolerated:

   • Provides cardiovascular and renal benefits beyond glucose control 1, 3
   • Has lower hypoglycemia risk than insulin or insulin secretagogues 3, 4

Monitoring After Medication Reduction

• Check blood glucose more frequently during the first 2 weeks after medication changes 1
• Schedule follow-up within 2-4 weeks to assess for any adverse effects 1
• Re-check A1C in 3 months to ensure it remains in an appropriate range (7-8%) 1
• Monitor for symptoms of hyperglycemia (excessive thirst, frequent urination) 1

Important Considerations

• Deintensification of diabetes treatment in older adults improves quality of life by reducing treatment burden and hypoglycemia risk 1
• Hypoglycemia in older adults increases risk of falls, cognitive impairment, and cardiovascular events 1
• The benefits of tight glycemic control (A1C <7%) are primarily seen in younger patients with longer life expectancy 1
• For patients >75 years, avoiding hypoglycemia and symptomatic hyperglycemia should be prioritized over achieving tight control 1

Common Pitfalls to Avoid

• Reducing all medications simultaneously can lead to rebound hyperglycemia 1
• Failing to increase monitoring during medication changes 1
• Not considering the patient's meal patterns when adjusting medications that work primarily at mealtimes (like nateglinide) 1, 2
• Overlooking the non-glycemic benefits of certain medications (like empagliflozin's cardiovascular benefits) 1, 3