How to manage a diabetic patient with an A1C of 9.0 on Lantus (Insulin Glargine) 60 units and Trulicity (Dulaglutide) 4.5?

Management of Poorly Controlled Type 2 Diabetes in a 68-Year-Old Patient

For a 68-year-old diabetic patient with an A1C of 9.0% currently on Lantus 60 units, sliding scale insulin, and Trulicity 4.5 mg, intensification of treatment is necessary with priority given to adding an SGLT2 inhibitor to reduce cardiovascular and renal risk while improving glycemic control.

Current Treatment Assessment

• The patient's A1C of 9.0% indicates poor glycemic control despite being on multiple medications, including basal insulin (Lantus 60 units), sliding scale insulin, and maximum dose GLP-1 RA (Trulicity 4.5 mg) 1
• This level of A1C is significantly above the recommended target of <7.0% for most patients with type 2 diabetes, indicating need for treatment intensification 1
• The current regimen includes two injectable therapies but lacks an SGLT2 inhibitor, which would provide complementary benefits 1

Recommended Treatment Approach

Add an SGLT2 Inhibitor

• Add an SGLT2 inhibitor with proven cardiovascular and renal benefits to the current regimen, regardless of A1C goal, due to the patient's age (68) which places them at higher cardiovascular risk 1
• SGLT2 inhibitors provide complementary benefits to GLP-1 RAs and insulin by different mechanisms of action 1
• This addition aligns with current guidelines that recommend SGLT2 inhibitors for patients with established cardiovascular disease or multiple risk factors 1

Optimize Current Insulin Regimen

• Evaluate the current insulin regimen (Lantus and sliding scale) for optimization 1
• Consider converting the sliding scale to fixed mealtime insulin doses if patient is experiencing significant glycemic variability 1
• Ensure proper insulin injection technique is being used to maximize effectiveness 1

Consider Metformin Status

• If not already on metformin, consider adding it as it remains the preferred first-line agent and can be safely used with eGFR ≥30 mL/min/1.73 m² 1
• If already on metformin, ensure maximum tolerated dose is being used 1

Monitoring and Follow-up

• Reassess A1C in 3 months after treatment changes 1
• Monitor for hypoglycemia, especially with the combination of insulin and other glucose-lowering medications 1
• Evaluate kidney function regularly, particularly when using SGLT2 inhibitors 1
• Consider CGM (continuous glucose monitoring) to identify patterns of hyperglycemia and hypoglycemia 1

Special Considerations

• At age 68 with poorly controlled diabetes (A1C 9.0%), this patient is at high risk for both microvascular and macrovascular complications 1
• Dulaglutide (Trulicity) at 4.5 mg is already at maximum dose and has shown efficacy in reducing A1C by approximately 1.0-1.5% in clinical trials 2
• The combination of GLP-1 RA and SGLT2 inhibitor has complementary mechanisms and can provide additive benefits for both glycemic control and cardiorenal protection 1
• Weight management should be considered as part of the overall treatment strategy, with both GLP-1 RAs and SGLT2 inhibitors offering weight reduction benefits 1

Common Pitfalls to Avoid

• Avoid clinical inertia: Failure to intensify therapy despite suboptimal control (A1C 9.0%) leads to prolonged hyperglycemia and increased complication risk 1, 3
• Avoid focusing solely on A1C: Treatment should address both glycemic control and cardiovascular/renal risk reduction 1
• Avoid overlooking hypoglycemia risk: With multiple glucose-lowering agents, especially insulin, careful monitoring for hypoglycemia is essential 1
• Avoid neglecting patient education: Ensure the patient understands proper administration of multiple injectable medications and recognizes signs of hypoglycemia 1

By implementing these recommendations, the goal is to improve glycemic control while reducing the risk of diabetes-related complications in this 68-year-old patient with poorly controlled type 2 diabetes.