From the Guidelines
The next step in managing this 70-year-old man with T2DM and an HbA1C of 8.7% on gliclazide and sitagliptin/metformin would be to add an SGLT-2 inhibitor like empagliflozin (10 mg daily) to his current regimen, as it provides cardiovascular and renal protection in addition to reducing A1C levels 1. This recommendation is based on the patient's insufficient current regimen to achieve the typical A1C target of <7.0%, indicating the need for treatment intensification. According to the 2020 expert consensus decision pathway on novel therapies for cardiovascular risk reduction in patients with type 2 diabetes, SGLT-2 inhibitors with demonstrated CV benefit, such as empagliflozin, should be initiated at the lowest dose tested in CV and renal outcomes trials, which is 10 mg daily 1. When adding empagliflozin, the patient should be monitored for potential side effects, including genital infections and volume depletion. Key considerations for the use of SGLT-2 inhibitors include:
- Monitoring for adverse effects such as genital fungal infections, urinary tract infections, and euglycemic diabetic ketoacidosis 1
- Using caution in patients with prior amputation, severe peripheral neuropathy, severe peripheral vascular disease, or active diabetic foot ulcers or soft tissue infections 1
- Considering the potential increased risk of bone fractures with canagliflozin, although this is not a concern with empagliflozin 1 If empagliflozin is contraindicated or not tolerated, alternative approaches could be considered, such as adding a GLP-1 receptor agonist or initiating basal insulin therapy. The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) emphasize the importance of individualizing glycemic targets and glucose-lowering therapies, taking into account the patient's preferences, needs, and values 2. In this case, the addition of an SGLT-2 inhibitor like empagliflozin to the patient's current regimen is a reasonable next step to improve glycemic control and reduce cardiovascular risk.
From the Research
Management of Type 2 Diabetes Mellitus
The patient in question is a 70-year-old man with Type 2 Diabetes Mellitus (T2DM) and an HbA1C of 8.7% on gliclazide 30mg BID and sitagliptin/metformin 50mg-1000mg OD. To manage this patient, the following points should be considered:
- The current treatment regimen includes a sulfonylurea (gliclazide) and a dipeptidyl peptidase-4 (DPP-4) inhibitor (sitagliptin) in combination with metformin 3, 4, 5.
- The patient's HbA1C level is above the target range, indicating the need for adjustment of the treatment regimen.
- In elderly patients with T2DM, the use of agents associated with hypoglycemia, such as sulfonylureas, should be minimized 6, 7.
- The addition of a third oral antihyperglycemic agent, such as a glucagon-like peptide-1 (GLP-1) receptor analogue, to the current regimen may be considered 6, 4, 5.
- The choice of treatment should take into account the patient's age, kidney function, and risk of hypoglycemia 7.
Treatment Options
Some potential treatment options for this patient include:
- Continuing the current regimen and monitoring the patient's HbA1C level closely.
- Adding a GLP-1 receptor analogue to the current regimen, as this class of drugs has been shown to be effective and well-tolerated in elderly patients with T2DM 6.
- Replacing gliclazide with a different sulfonylurea or another class of medication, such as a thiazolidinedione or a sodium-glucose cotransporter 2 inhibitor, in combination with sitagliptin and metformin 4, 5.
- Considering insulin therapy if the patient's HbA1C level remains above target despite adjustments to the oral medication regimen 7.