From the Guidelines
I strongly recommend implementing lifestyle modifications, particularly regular physical activity, to reduce the hemoglobin A1c (HbA1c) level in this 71-year-old female patient with type 2 diabetes mellitus (T2DM). The patient is currently taking Jardiance (Empagliflozin) 25mg and Metformin 500mg, with a persistent elevated HbA1c level of 8.1%. According to the most recent and highest quality study 1, people with diabetes should perform aerobic and resistance exercise regularly, with aerobic activity bouts ideally lasting at least 10 min, and a goal of 30 min/day or more most days of the week for adults with type 2 diabetes. Daily exercise, or at least not allowing more than 2 days to elapse between exercise sessions, is recommended to decrease insulin resistance, regardless of diabetes type. A systematic review and meta-analysis found that higher frequency of regular leisure-time physical activity was more effective in reducing A1C levels. Some key points to consider:
- Regular physical activity can help reduce HbA1c levels and improve insulin sensitivity
- Aerobic and resistance exercises are recommended for adults with type 2 diabetes
- Daily exercise or regular physical activity with no more than 2 days of rest in between is recommended
- A wide range of activities, including yoga, tai chi, and other types, can have significant impacts on A1C, flexibility, muscle strength, and balance
- Flexibility and balance exercises may be particularly important in older adults with diabetes to maintain range of motion, strength, and balance Additionally, considering the patient's age and comorbidities, it is essential to personalize goals for glycemic control, taking into account benefits and harms of pharmacotherapy, patient preferences, general health, and life expectancy, as recommended by the American College of Physicians 1. However, given the patient's current HbA1c level and age, the primary focus should be on lifestyle modifications, particularly regular physical activity, to reduce the HbA1c level and improve overall health outcomes.
From the FDA Drug Label
In Combination with Linagliptin as Add-On to Metformin Therapy A total of 686 patients with type 2 diabetes participated in a double-blind, active-controlled study to evaluate the efficacy and safety of JARDIANCE 10 mg or 25 mg in combination with linagliptin 5 mg compared to the individual components Patients with type 2 diabetes inadequately controlled on at least 1500 mg of metformin per day entered a single-blind placebo run-in period for 2 weeks. At the end of the run-in period, patients who remained inadequately controlled and had an HbA1c between 7 and 10. 5% were randomized 1:1:1:1:1 to one of 5 active-treatment arms of JARDIANCE 10 mg or 25 mg, linagliptin 5 mg, or linagliptin 5 mg in combination with 10 mg or 25 mg JARDIANCE as a fixed dose combination tablet. At Week 24, JARDIANCE 10 mg or 25 mg used in combination with linagliptin 5 mg provided statistically significant improvement in HbA1c (p-value <0.0001) and FPG (p-value <0. 001) compared to the individual components in patients who had been inadequately controlled on metformin.
The patient is currently taking Jardiance (Empagliflozin) 25mg and Metformin 500mg. To reduce the HbA1c level, adding linagliptin 5mg to the current treatment regimen can be considered, as it has been shown to provide statistically significant improvement in HbA1c compared to the individual components in patients inadequately controlled on metformin 2.
- Key points:
- The patient's current HbA1c level is 8.1%, which is above the target level.
- Adding linagliptin 5mg to the current treatment regimen of Jardiance (Empagliflozin) 25mg and Metformin 500mg may help reduce the HbA1c level.
- The efficacy and safety of JARDIANCE in combination with linagliptin 5mg have been evaluated in a double-blind, active-controlled study 2.
From the Research
Additional Interventions to Reduce HbA1c Levels
To reduce the hemoglobin A1c (HbA1c) level in a 71-year-old female patient with type 2 diabetes mellitus (T2DM), several additional interventions can be considered:
- Insulin Therapy: According to 3, insulin is considered alone or in combination with oral agents when HbA1c is ≥ 7.5% (≥ 58 mmol/mol). The preferred method of insulin initiation in T2DM is to begin by adding a long-acting (basal) insulin or once-daily premixed/co-formulation insulin, alone or in combination with glucagon-like peptide-1 receptor agonist (GLP-1 RA) or in combination with other oral antidiabetic drugs (OADs).
- GLP-1 Receptor Agonist: The study 4 compared oral semaglutide, a GLP-1 receptor agonist, with sitagliptin in patients with type 2 diabetes uncontrolled with metformin with or without sulfonylurea. The results showed that oral semaglutide, 7 mg/d and 14 mg/d, resulted in significantly greater reductions in HbA1c over 26 weeks.
- Insulin Pump Therapy: The study 5 used a continuous subcutaneous insulin infusion (CSII) in a patient with type 2 diabetes and severe insulin resistance. The patient's A1C was reduced from > 14% to 8.3% after 5 months of follow-up.
- Adjusting Current Medications: The study 6 provided guidelines for insulin dosing and titration in ambulatory care of type 2 diabetes. The guidelines recommend adjusting insulin doses based on self-monitoring of plasma glucose pre-meal/fasting plasma glucose (FPG) values.
Considerations for Implementing Additional Interventions
When implementing these additional interventions, the following considerations should be taken into account:
- Monitoring and Titration: Regular monitoring of blood glucose levels and adjustment of insulin doses or other medications as needed 3, 6.
- Patient Education: Educating the patient on the proper use of insulin pumps, glucose monitoring, and medication management 5.
- Individualized Treatment: Tailoring the treatment plan to the individual patient's needs and goals, taking into account factors such as age, comorbidities, and lifestyle 7.