From the Guidelines
For this 45-year-old female with poorly controlled diabetes (HbA1c of 11) and mixed hyperlipidemia who didn't tolerate metformin or Jardiance and is currently only on Lantus 10 units and rosuvastatin 20 mg, I recommend intensifying her diabetes treatment with a GLP-1 receptor agonist such as semaglutide (Ozempic) starting at 0.25 mg weekly for 4 weeks, then increasing to 0.5 mg weekly, with potential further titration to 1 mg weekly as needed. Her Lantus dose should be increased gradually, targeting fasting glucose of 80-130 mg/dL, likely requiring 20-30 units or more given her high HbA1c, as suggested by the American Diabetes Association standards of medical care in diabetes 1. For her mixed hyperlipidemia, continue rosuvastatin 20 mg and consider adding ezetimibe 10 mg daily if LDL remains elevated, based on the recommendations for statin and combination treatment in persons with diabetes 1. A comprehensive approach should include:
- Dietary counseling focusing on carbohydrate counting and portion control
- Regular physical activity (150 minutes weekly of moderate exercise)
- Monitoring blood glucose 2-4 times daily GLP-1 agonists are particularly beneficial as they improve glycemic control without hypoglycemia risk, promote weight loss, and have cardiovascular benefits, as noted in the 2020 standards of medical care in diabetes 1. This approach addresses both her diabetes and dyslipidemia while avoiding medications she previously couldn't tolerate.
From the Research
Patient Profile
- 45-year-old female patient with an HbA1c level of 11 and mixed hyperlipidemia
- Currently on 10 units of Lantus and rosuvastatin 20 mg
- Did not tolerate metformin or Jardiance (empagliflozin)
Treatment Options
- Metformin is the first-line treatment for type 2 diabetes, but the patient did not tolerate it 2
- Jardiance (empagliflozin) is an alternative option, but the patient also did not tolerate it 3, 4
- Other treatment options may be considered, such as sulfonylureas or other SGLT2 inhibitors
Considerations
- The patient's high HbA1c level indicates poor glycemic control, which increases the risk of cardiovascular complications 3, 4
- The patient's mixed hyperlipidemia also increases the risk of cardiovascular disease 5
- The use of empagliflozin has been shown to have cardioprotective effects, particularly in patients with established cardiovascular disease 3, 4
Potential Next Steps
- Consider alternative treatment options, such as sulfonylureas or other SGLT2 inhibitors, to improve glycemic control and reduce cardiovascular risk
- Monitor the patient's HbA1c level and lipid profile regularly to assess the effectiveness of treatment and adjust as needed
- Consider the patient's individual characteristics, such as her gastrointestinal intolerance to metformin, when selecting a treatment option 2, 6