Should a patient with well-controlled diabetes (HbA1c of 5.7) stop taking Synjardy (empagliflozin and metformin)?

Should Synjardy Be Discontinued in a Patient with HbA1c 5.7%?

Yes, you should strongly consider deintensifying or discontinuing Synjardy in this patient with an HbA1c of 5.7%, as this level is well below the 6.5% threshold where treatment deintensification is recommended by major guidelines. 1

Guideline-Based Rationale for Deintensification

The American College of Physicians provides explicit guidance on this clinical scenario:

• Clinicians should consider deintensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%. 1

• No trials demonstrate that targeting HbA1c levels below 6.5% improves clinical outcomes, and pharmacologic treatment to below this target has substantial harms. 1

• The ACCORD trial, which targeted HbA1c <6.5% and achieved 6.4%, was discontinued early due to increased overall and cardiovascular-related death and severe hypoglycemic events. 1

• More intensive treatment to achieve lower targets is more costly and associated with increased patient burden without demonstrated benefit. 1

Specific Approach to Deintensification

When a patient achieves an HbA1c level less than 6.5%, you should deintensify treatment by: 1

• Reducing the dosage of one or both components
• Removing one medication if the patient is receiving more than one agent
• Discontinuing pharmacologic treatment entirely if appropriate

Metformin Considerations

While metformin has a more favorable safety profile than many diabetes medications: 1

• Metformin is not associated with hypoglycemia and is generally well-tolerated and low-cost 1
• However, it still results in use of additional medication with little to no benefit at HbA1c levels below 7% 1
• The balance between benefits and harms is uncertain with metformin at lower HbA1c levels 1

SGLT2 Inhibitor (Empagliflozin) Considerations

Important caveat: If this patient has established atherosclerotic cardiovascular disease (ASCVD) or heart failure, the decision becomes more nuanced: 1

• SGLT2 inhibitors with demonstrated cardiovascular benefit should be continued in patients with type 2 diabetes and clinical ASCVD, even if glycemic control is excellent 1
• The cardiovascular benefits of empagliflozin cannot be ascribed solely to glycemic control 1
• Secondary analyses demonstrate that baseline A1C does not modify the cardiovascular benefits of these agents 1

Practical Algorithm for This Patient

If the patient does NOT have ASCVD or heart failure:

• Discontinue Synjardy entirely and monitor with lifestyle modifications 1
• Alternatively, discontinue empagliflozin and continue metformin alone at reduced dose 1
• Recheck HbA1c in 3 months to ensure glycemic control is maintained 1

If the patient HAS established ASCVD or heart failure:

• Continue empagliflozin for cardiovascular risk reduction 1
• Consider discontinuing or reducing metformin 1
• Adjust doses of any other medications that may cause hypoglycemia 1

Critical Monitoring After Deintensification

• Emphasize the importance of lifestyle interventions, including exercise, dietary changes, and weight loss 1
• Recheck HbA1c every 3-6 months after deintensification 1
• Monitor for return of hyperglycemic symptoms 1
• Smoking cessation, adequate blood pressure control, and lipid management should take priority over achieving tighter glycemic control 1

Common Pitfalls to Avoid

• Do not continue intensive pharmacologic therapy simply because the patient has diabetes - an HbA1c of 5.7% indicates overtreatment in most patients without cardiovascular indications 1
• Do not assume all diabetes medications must be continued indefinitely - regular reassessment and deintensification when appropriate is evidence-based practice 1
• Do not overlook cardiovascular indications for SGLT2 inhibitors - these agents have benefits beyond glycemic control in select populations 1