Medication Regimen Adjustment for 88-Year-Old with A1C 8.0%
Simplify this regimen immediately by discontinuing Januvia (sitagliptin) and consider reducing or stopping Jardiance (empagliflozin), while maintaining metformin and optimizing the Lantus dose to achieve a more appropriate A1C target of 7.5-8.0% for this elderly patient. 1
Rationale for Regimen Simplification
Age-Appropriate Glycemic Targets
For an 88-year-old patient, an A1C of 8.0% is actually reasonable and may not require aggressive intensification. 1 The current four-drug regimen represents excessive polypharmacy for minimal additional benefit at this age.
The American Diabetes Association and European Association for the Study of Diabetes recommend that elderly patients with long-standing or complicated disease should have less ambitious glycemic targets, with an A1C of 7.5-8.0% being acceptable. 1 This target should transition upward as age increases and capacity for self-care declines.
The risk of hypoglycemic events can be detrimental in the elderly and may lead to increased morbidity and mortality, including falls, fractures, and cardiovascular events. 1 No randomized controlled trials have shown benefits of tight glycemic control on clinical outcomes and quality of life in elderly ambulatory patients. 1
Specific Medication Adjustments
Discontinue Januvia (Sitagliptin):
With four concurrent diabetes medications, the incremental benefit of sitagliptin is minimal and adds unnecessary complexity and cost. 1 The combination of metformin, an SGLT2 inhibitor, and basal insulin already provides comprehensive glycemic coverage.
Studies show that sitagliptin combined with basal insulin is most useful in treating elderly patients with mild to moderate hyperglycemia, 1 but this patient already has adequate basal insulin coverage with Lantus.
Consider Reducing or Stopping Jardiance (Empagliflozin):
While SGLT2 inhibitors have cardiovascular and renal benefits, elderly patients are at increased risk for volume depletion, orthostatic hypotension, and falls. 1
Jardiance should be used cautiously in patients with poor mobility or urinary incontinence, 1 which are common in octogenarians.
If cardiovascular disease or heart failure is present, continuing Jardiance at a reduced dose (10 mg) may be justified for its cardioprotective effects. 2
Maintain Metformin:
Metformin should be continued if renal function is adequate (CrCl >30 mL/min), 1 as it provides foundational glucose control with minimal hypoglycemia risk.
Monitor renal function regularly and discontinue if CrCl falls below 30 mL/min to avoid lactic acidosis risk. 1
Optimize Lantus (Insulin Glargine):
The basal insulin dose should be the primary tool for achieving the target A1C of 7.5-8.0%. 1
For elderly patients with reduced oral intake, starting insulin doses should be reduced to 0.1-0.15 units/kg/day, given mainly as basal insulin. 1
Avoid overbasalization—clinical signals include basal dose >0.5 units/kg, high bedtime-morning glucose differential (>50 mg/dL), hypoglycemia, and high variability. 1
Monitoring Strategy
Measure A1C every 3 months 1 to assess whether the simplified regimen maintains adequate control.
Home blood glucose monitoring should be individualized based on the pharmacologic regimen. 1 With basal insulin alone, fasting glucose checks may suffice; if glucose variability persists, add pre-dinner checks.
Monitor for hypoglycemia awareness, falls, and cognitive changes, 1 as these are critical safety outcomes in elderly patients that outweigh modest A1C improvements.
Common Pitfalls to Avoid
Avoid aggressive glucose lowering in pursuit of A1C <7.0% in this age group. 1 The risks of hypoglycemia, polypharmacy, and treatment burden outweigh any theoretical microvascular benefits.
Do not continue all four medications simply because the patient is "on them." 1 Therapeutic inertia works both ways—deprescribing is as important as prescribing in elderly patients.
Avoid sliding-scale insulin regimens, as they increase hypoglycemia risk. 1
Do not use long-acting sulfonylureas due to prolonged hypoglycemia risk, 1 though this patient is not currently on one.
Practical Implementation
Proposed simplified regimen:
- Metformin (continue current dose if tolerated and renal function adequate)
- Lantus (optimize dose to achieve fasting glucose 100-140 mg/dL)
- Consider Jardiance 10 mg daily only if cardiovascular/renal indications exist
- Discontinue Januvia
This approach prioritizes safety, reduces pill burden, lowers costs, and maintains adequate glycemic control appropriate for an 88-year-old patient. 1