What to discuss with a 71-year-old female patient with leukocytosis and an HbA1C of 11.3?

From the Guidelines

The patient should be treated to minimize symptoms related to hyperglycemia, and an HbA1c target should not be strictly applied due to her advanced age and potential for limited life expectancy, as the harms of tight glycemic control may outweigh the benefits in this population. The patient's elevated white blood cell count and HbA1c of 11.3 suggest poorly controlled diabetes and a possible infection, which should be addressed promptly by her doctor. According to the American College of Physicians guidance statement 1, clinicians should personalize goals for glycemic control in patients with type 2 diabetes, taking into account the patient's general health, life expectancy, treatment burden, and costs of care. For older adults, the American Diabetes Association recommends considering a less stringent A1C goal, such as <8% (64 mmol/mol), for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, or extensive comorbid conditions 2.

The patient's age and potential for limited life expectancy suggest that a more relaxed approach to glycemic control may be appropriate, focusing on minimizing symptoms and avoiding hypoglycemia rather than achieving a specific HbA1c target. The VA/DoD guideline 1 recommends an HbA1c target range of 8.0-9.0% for patients with type 2 diabetes and a life expectancy of less than 5 years, significant comorbid conditions, or advanced complications of diabetes.

Key considerations in managing this patient's diabetes include:

• Monitoring blood glucose levels regularly to avoid hypoglycemia and symptomatic hyperglycemia
• Adjusting diabetes medication to minimize symptoms and avoid hypoglycemia
• Considering treatment regimen simplification or deintensification to reduce complexity and burden on the patient
• Providing education on diabetes self-management and addressing any social determinants of health that may impact the patient's ability to manage her diabetes.

From the FDA Drug Label

The risk of metformin-associated lactic acidosis increases with the patient's age because elderly patients have a greater likelihood of having hepatic, renal, or cardiac impairment than younger patients. Assess renal function more frequently in elderly patients Before initiating metformin hydrochloride tablets, obtain an estimated glomerular filtration rate (eGFR). Metformin hydrochloride tablets are contraindicated in patients with an eGFR less than 30 mL/min/1.73 m 2 In patients taking metformin hydrochloride tablets whose eGFR falls below 45 mL/min/1. 73 m 2, assess the benefit and risk of continuing therapy.

The patient is 71 years old with an HbA1C of 11.3 and leukocytosis. Key considerations for this patient include:

• Renal function: Assess the patient's renal function by obtaining an estimated glomerular filtration rate (eGFR) before initiating metformin therapy.
• Age-related risks: The patient's age increases the risk of metformin-associated lactic acidosis, so frequent monitoring of renal function is necessary.
• HbA1C management: The patient's high HbA1C level indicates poor glucose control, but metformin therapy should be approached with caution due to the patient's age and potential renal impairment.
• Leukocytosis: The patient's leukocytosis may indicate an underlying infection or other condition that could affect metformin therapy or increase the risk of lactic acidosis. [3] [4]

From the Research

Patient Discussion Points

To discuss with a 71-year-old female patient with leukocytosis and an HbA1C of 11.3, consider the following points:

• The patient's high HbA1C level indicates poor glycemic control, which is a concern for patients with type 2 diabetes 5.
• Leukocytosis, or elevated white blood cell count, can be a sign of infection or inflammation, which may be related to the patient's diabetes or other underlying conditions.
• The patient's age and HbA1C level are important factors to consider when determining the best course of treatment, as older adults may be more susceptible to hypoglycemia and other complications 6.
• Studies have shown that combination therapy with oral medications, such as metformin and sulfonylurea, can be effective in reducing HbA1C levels in patients with type 2 diabetes 7.
• However, for patients with HbA1C levels above 9%, insulin therapy may be necessary to achieve adequate glycemic control 5.
• It is also important to consider the patient's overall health and medical history, including any underlying conditions or medications that may be contributing to their leukocytosis and poor glycemic control.

Treatment Considerations

When discussing treatment options with the patient, consider the following:

• The patient's HbA1C level and leukocytosis suggest that their current treatment regimen may not be adequate, and adjustments may be necessary to achieve better glycemic control.
• Combination therapy with oral medications, such as metformin and sulfonylurea, may be effective in reducing HbA1C levels, but insulin therapy may be necessary for patients with HbA1C levels above 9% 5.
• The patient's age and medical history should be taken into account when determining the best course of treatment, and the patient should be closely monitored for signs of hypoglycemia and other complications.
• Early attainment of HbA1C <7.0% appears predictive of long-term glycemic control, suggesting that timely modification of treatment strategies is important to minimize therapeutic inertia 8.