From the Guidelines
For a patient with hyperglycemia who is already on low-dose Ozempic (semaglutide) and high-dose metformin but refuses insulin injections, the next appropriate medication would be an SGLT-2 inhibitor. This recommendation is based on the consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) 1, which emphasizes the importance of patient preference and clinical characteristics in selecting the next glucose-lowering medication after metformin. Given the patient's current regimen and refusal of insulin injections, an SGLT-2 inhibitor such as empagliflozin (Jardiance), dapagliflozin (Farxiga), or canagliflozin (Invokana) would be a suitable addition, offering a different mechanism of action that promotes glucose excretion through the kidneys. Some key points to consider when prescribing SGLT-2 inhibitors include:
- Starting doses, such as empagliflozin 10mg daily or dapagliflozin 5mg daily, with possible dose increases if needed
- Assessing kidney function before initiation, as reduced renal function may decrease the medication's effectiveness
- Counseling patients about potential side effects, including genital mycotic infections, urinary tract infections, and the rare risk of diabetic ketoacidosis
- Considering alternative options, such as DPP-4 inhibitors or thiazolidinediones, if SGLT-2 inhibitors are contraindicated, although these may have different efficacy profiles for weight management.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment Options for Type 2 Diabetes
The patient is currently on low-dose Ozempic (semaglutide) and high-dose Metformin (metformin) but does not want to take insulin (intramuscular injections). Considering this, the next glucose-lowering medication could be:
- Oral semaglutide, as it has been shown to be effective in reducing HbA1c levels and body weight, with a low risk of hypoglycemia 2, 3, 4
- Increasing the dose of Ozempic (semaglutide) to a higher dose, as studies have shown that higher doses can lead to greater reductions in HbA1c and body weight 5, 6
Efficacy and Safety of Semaglutide
Semaglutide has been proven to be safe and effective in patients with type 2 diabetes, with a low risk of hypoglycemia and significant reductions in HbA1c and body weight 2, 3, 5, 6, 4
- The most common adverse events associated with semaglutide are gastrointestinal, such as nausea and diarrhea 2, 5, 4
- Semaglutide has been shown to have a cardiovascular benefit, reducing the risk of major adverse cardiovascular events 3
Considerations for Treatment
When considering the next glucose-lowering medication, it is essential to take into account the patient's preferences and tolerability to the medication, as well as the potential benefits and risks associated with each treatment option 2, 4
- Oral semaglutide may be a more acceptable option for patients who are intolerant to injections or prefer an oral medication 4
- Increasing the dose of Ozempic (semaglutide) may be a viable option for patients who are already on the medication and are experiencing adequate glucose control but require further reduction in HbA1c levels 5, 6