Management of Poorly Controlled Type 2 Diabetes with A1C 8.7%
For a patient with persistently elevated A1C of 8.7% on current therapy, intensification of treatment is strongly recommended with the addition of basal insulin therapy.
Current Medication Assessment
- Patient is currently taking multiple medications:
Treatment Intensification Recommendations
1. Optimize Insulin Therapy
- Increase basal insulin (glargine) dose by 10-20% and titrate based on fasting blood glucose levels 2
- Target fasting plasma glucose of 80-130 mg/dL 1
- Consider adding prandial insulin, starting with one dose at the largest meal (4 units or 10% of basal dose) 2
- Titrate insulin dose by 2 units every 3 days until target glucose is reached 2
2. Medication Adjustments
- Continue metformin at current dose as it remains the foundation of therapy 1
- Continue SGLT2 inhibitor (Farxiga) as it provides cardiovascular and renal benefits independent of glucose control 1
- Consider replacing Tradjenta (DPP-4 inhibitor) with a GLP-1 receptor agonist for more potent glucose-lowering effect 1, 3
3. Monitoring Recommendations
- Implement structured self-monitoring of blood glucose before meals and at bedtime 3
- Check A1C in 3 months to evaluate treatment effectiveness 1
- Monitor for hypoglycemia, especially as insulin doses are increased 2
Rationale for Recommendations
- The patient's A1C has increased from 8.6% to 8.7% despite multiple medications, indicating treatment failure 1
- For patients with A1C >8.5%, insulin therapy intensification is recommended by guidelines 1
- The combination of basal insulin plus metformin is particularly effective for lowering glycemia while limiting weight gain 1
- Early addition of insulin therapy is recommended when target glycemic goals are not achieved or sustained 1
Common Pitfalls to Avoid
- Delaying insulin intensification when oral agents fail to achieve glycemic targets 1, 2
- Adding more medications before optimizing current therapy can increase side effects without proportional benefit 3
- Failing to address potential adherence issues with current medications 3
- Not considering hypoglycemia risk when intensifying insulin therapy, especially in patients on sulfonylureas 1
Special Considerations
- Monitor for vitamin B12 deficiency with long-term metformin use 3
- Ensure proper insulin injection technique and site rotation 2
- If severe hypoglycemia occurs, consider modifying treatment goals 1
- Farxiga (SGLT2 inhibitor) can be continued even with eGFR as low as 25 mL/min/1.73m² for cardiovascular and renal benefits 1
By implementing these changes, the patient has a high likelihood of achieving better glycemic control and reducing the risk of diabetes-related complications.