Management of a 79-Year-Old with A1C 7.0 on Empagliflozin 25mg
Continue the current regimen of empagliflozin 25mg without intensification, as the A1C of 7.0% is at goal for a healthy older adult and the patient is already on the maximum dose of a medication with proven cardiovascular and renal benefits.
Rationale for Current Management
The patient's A1C of 7.0% meets the recommended glycemic target for healthy older adults (A1C <7.0-7.5%) according to the American Diabetes Association 2024 guidelines 1. For older adults who are healthy with few coexisting chronic illnesses and intact cognitive and functional status, this A1C range balances glycemic control with the risk of hypoglycemia and treatment burden 1.
The patient is already receiving empagliflozin 25mg, which is the maximum approved dose 2. This dose has demonstrated:
- Significant cardiovascular benefits, including 38% reduction in cardiovascular death, 35% reduction in heart failure hospitalization, and 32% reduction in all-cause mortality in the EMPA-REG OUTCOME trial 3
- Renal protective effects with reduced progression of kidney disease 1
- Consistent benefits across the spectrum of heart failure risk, even in patients without established heart failure 4
Key Considerations for Older Adults
When to Consider Treatment Simplification or Deintensification
Monitor for situations that would warrant regimen changes 1:
- Severe or recurrent hypoglycemia (though empagliflozin carries low hypoglycemia risk as monotherapy)
- Cognitive or functional decline that impairs self-management
- Wide glucose excursions suggesting poor glycemic stability
- Significant changes in social circumstances (loss of caregiver, change in living situation, financial difficulties)
- Development of complex/intermediate health status (multiple chronic illnesses, instrumental ADL impairments, mild-to-moderate cognitive impairment), which would warrant raising the A1C target to <8.0% 1
Monitoring Plan
Continue routine monitoring 1:
- A1C every 3-6 months to ensure maintenance of glycemic control
- Renal function assessment before each visit, as empagliflozin should be discontinued if eGFR falls persistently below 45 mL/min/1.73 m² 2
- Blood pressure monitoring at every visit, as empagliflozin provides modest blood pressure reduction 5, 6
- Assessment for genital mycotic infections and urinary tract infections, the most common adverse effects 5, 3
Important Safety Considerations
Sick day management is critical for SGLT2 inhibitors 1. Instruct the patient to temporarily stop empagliflozin during acute illness with:
- Vomiting or diarrhea resulting in significant fluid losses
- Inability to maintain adequate oral fluid intake
- Signs of volume depletion (lightheadedness, dizziness, decreased urine output)
- Moderate or high ketones (check ketones during illness) 1
Resume empagliflozin within 24-48 hours of eating and drinking normally, or seek healthcare provider assistance if symptoms persist beyond 72 hours 1.
When NOT to Intensify Treatment
Treatment intensification would not be appropriate in this case because:
- The A1C is already at the recommended goal for this age group 1
- The patient is on maximum dose empagliflozin with proven mortality benefit 2, 3
- Overtreatment in older adults increases risks of hypoglycemia, falls, fractures, and cognitive impairment without additional benefit 1
- The cardiovascular and renal benefits of empagliflozin are largely independent of glycemic control 5, 6, 3
Alternative Scenario: If A1C Were Above Goal
If the A1C were >7.5% and intensification were needed, consider adding 1:
- GLP-1 receptor agonist (dulaglutide, liraglutide, or injectable semaglutide) for additional cardiovascular benefit and glucose lowering
- Metformin if not already prescribed and renal function permits
- Basal insulin only if A1C ≥10% or glucose ≥300 mg/dL with catabolic features 7