From the Guidelines
The next recommended step for this 70-year-old man with type 2 diabetes and an elevated Hemoglobin A1C (HbA1C) level is to add a GLP-1 receptor agonist or an SGLT2 inhibitor to his current regimen, as these medications have demonstrated benefits in reducing A1C levels and improving cardiovascular outcomes, as suggested by the 2021 standards of medical care in diabetes 1.
Given the patient's age and potential for high ASCVD risk, the choice of medication added to metformin should be based on drug-specific effects and patient factors, including the presence of established ASCVD or indicators of high ASCVD risk, heart failure, CKD, and other comorbidities 1.
Some key points to consider when selecting the next step in treatment include:
- The patient's current regimen of Gliclazide and Citicoline/Metformin is insufficient to achieve the target A1C level, indicating the need for treatment intensification 1.
- GLP-1 receptor agonists and SGLT2 inhibitors have been shown to have significant A1C-lowering effects, as well as benefits in terms of weight loss and cardiovascular protection 1.
- The choice between a GLP-1 receptor agonist and an SGLT2 inhibitor should be based on the patient's individual characteristics and preferences, including the presence of comorbidities and the risk of specific adverse drug effects 1.
Before starting either medication, it is essential to assess the patient's kidney function and educate him about potential side effects, such as nausea and injection site reactions with GLP-1 agonists, and genital infections and volume depletion with SGLT2 inhibitors.
If these options are contraindicated or not tolerated, basal insulin therapy could be considered as an alternative approach, taking into account the patient's clinical characteristics and preferences 1.
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 in question has type 2 diabetes with an elevated Hemoglobin A1C (HbA1C) level, currently controlled on Gliclazide and Citicoline/Metformin. Considering the patient's condition, the following treatment options can be explored:
- Insulin therapy: According to 2, insulin therapy is recommended for patients with type 2 diabetes and an initial A1C level greater than 9 percent, or if diabetes is uncontrolled despite optimal oral glycemic therapy.
- Combination therapy with DPP-4 inhibitor and SGLT2 inhibitor: Studies 3, 4, 5 suggest that combining a DPP-4 inhibitor and an SGLT2 inhibitor can be an effective and safe treatment option for type 2 diabetes, with complementary mechanisms of action and no increased risk of hypoglycemia or weight gain.
- GLP-1 receptor agonists: Research 6 indicates that GLP-1 receptor agonists may offer superior benefits compared to insulin therapy, with greater HbA1c reductions and weight loss.
Considerations for Treatment
When choosing a treatment option, the following factors should be considered:
- Glucose control: The ability of the treatment to reduce HbA1c levels and achieve optimal glycemic control.
- Adverse effects: The potential risks and side effects associated with each treatment option, such as hypoglycemia, weight gain, or cardiovascular events.
- Cost and adherence: The cost of the treatment and the patient's ability to adhere to the prescribed regimen.
- Quality of life: The impact of the treatment on the patient's overall quality of life, including any potential benefits or drawbacks.