From the Guidelines
For a 44-year-old female with an HbA1c of 11% who is already on empagliflozin-metformin 25-1000 mg daily with an average glucose of 150 mg/dL, I recommend adding a GLP-1 receptor agonist such as semaglutide (Ozempic) starting at 0.25 mg subcutaneously once weekly for 4 weeks, then increasing to 0.5 mg weekly. This recommendation is based on the most recent and highest quality study available, which suggests that GLP-1 agonists offer superior glycemic efficacy compared to additional oral agents when HbA1c remains elevated despite dual therapy 1. The patient's current regimen already includes two effective medications (metformin and an SGLT-2 inhibitor), but her HbA1c of 11% indicates poor control requiring intensification. Some key points to consider in this decision include:
- The patient's significant gap between current glycemic control and target
- The superior efficacy of GLP-1 agonists in reducing HbA1c levels
- The potential cardiovascular benefits and weight loss associated with GLP-1 agonists
- The importance of shared decision-making in discussions regarding treatment intensification, as emphasized in the standards of medical care in diabetes-2021 1 If an oral medication is strictly required, a DPP-4 inhibitor like sitagliptin 100 mg daily could be added, though it would likely be less effective, as suggested by the comparative effectiveness meta-analysis that each new class of non-insulin agents added to initial therapy with metformin generally lowers A1C approximately 0.7–1.0% 1. However, given the patient's poor glycemic control, a GLP-1 receptor agonist is the preferred choice due to its superior efficacy and potential benefits beyond glycemic control.
From the Research
Current Treatment and Condition
The patient is currently on Empagliflozin (Empagliflozin)-Metformin (Metformin) 25-1000 mg daily, with an average glucose level of 150 mg/dL and a Hemoglobin A1c (HbA1c) level of 11% 2, 3, 4, 5.
Considerations for Next Best Oral Medication
Given the patient's current treatment and condition, the following points are relevant:
- The patient is already on a combination of Empagliflozin and Metformin, which has been shown to be effective in improving glycemic control, body weight, and blood pressure with a low risk of hypoglycemia 2, 3, 5.
- The addition of Empagliflozin to Metformin therapy has been shown to be well tolerated and effective in patients with type 2 diabetes 4.
- The combination of Empagliflozin and Metformin is available as a single-pill combination, which can simplify treatment regimens and improve clinical outcomes 5.
- Alternative treatments, such as dulaglutide, have been compared to Empagliflozin in patients with type 2 diabetes inadequately controlled with metformin, sulfonylurea, and DPP4 inhibitor, with Empagliflozin showing greater HbA1c reduction and weight loss 6.
Potential Next Steps
Some potential next steps to consider are:
- Continuing the current treatment and monitoring the patient's condition to assess the effectiveness of the current regimen.
- Adjusting the dose of Empagliflozin or Metformin to optimize glycemic control.
- Considering the addition of another oral medication, such as a sulfonylurea or a DPP4 inhibitor, to the current regimen.
- Evaluating the patient's suitability for alternative treatments, such as dulaglutide, based on their individual needs and medical history.