From the Guidelines
The patient should continue their current medication regimen without changes, which includes Empagliflozin (Jardiance) 10 mg daily, Glipizide XL 10 mg every morning, Metformin 1000 mg twice daily with meals, and Pioglitazone (Actos) 45 mg daily with lunch, as the current HbA1c level is 7.5% and the goal is <7% 1. The patient is appropriately on cardiovascular protective medications including atorvastatin 40 mg daily, lisinopril 5 mg nightly, and aspirin 81 mg daily. Blood glucose monitoring should be performed when fasting, 2 hours after meals, and when experiencing symptoms of hypo/hyperglycemia. Lifestyle modifications are crucial, including:
- 150 minutes of weekly exercise
- weight loss
- dietary changes such as eating smaller, consistent meals throughout the day
- avoiding carbohydrates, fats, and sugary foods in favor of vegetables and lean meats. The patient has diabetic neuropathy with loss of sensation in both heels, requiring daily foot checks to prevent complications. They need to follow up with optometry for their annual diabetic eye exam. HbA1c and CMP tests were ordered, and a new glucose monitor will be provided since the patient lost theirs in Mexico. Given the patient's current medication regimen and the fact that their HbA1c level is close to the goal, it is reasonable to continue the current treatment plan and reassess in the future, taking into consideration the latest guidelines for the management of type 2 diabetes 1.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION ACTOS should be taken once daily without regard to meals. The management of antidiabetic therapy should be individualized. Ideally, the response to therapy should be evaluated using HbA1c which is a better indicator of long-term glycemic control than FPG alone. HbA1c reflects glycemia over the past two to three months In clinical use, it is recommended that patients be treated with ACTOS for a period of time adequate to evaluate change in HbA1c (three months) unless glycemic control deteriorates.
The patient's current HbA1c is 7.5, which is above the goal of <7. The patient is taking pioglitazone (Actos) 45 mg once daily, which is the maximum recommended dose. No medication changes were made today. The patient should continue to be monitored for adverse events related to fluid retention and liver enzyme monitoring is recommended. It is recommended to recheck HbA1c in three months to evaluate the response to therapy, unless glycemic control deteriorates. 2
The patient is also taking empagliflozin (Jardiance) 10 mg once daily, metformin 1000 mg twice daily, and glipizide XL 10 mg once daily. The patient's blood pressure and lipid profile are being managed with lisinopril 5 mg once daily and atorvastatin 40 mg once daily, respectively. The patient is also taking aspirin 81 mg once daily. The patient should continue to work on lifestyle changes, including diet and regular exercise, to help achieve glycemic control. 3
From the Research
Medication Management
- The patient is currently taking Empagliflozin (Jardiance) 10 mg tablet PO daily, which is a sodium glucose cotransporter-2 (SGLT2) inhibitor that has been shown to be effective in improving glycemic control in patients with type 2 diabetes mellitus (T2D) 4, 5.
- The patient is also taking Glipizide XL 10 mg tablet PO every morning, Metformin 1000 mg PO BID with meals daily, and Pioglitazone (Actos) 45 mg tablet PO daily with lunch, which are all part of their medication regimen to manage their T2D.
- The use of Empagliflozin has been associated with a low risk of hypoglycemia, weight loss, and moderate reductions in blood pressure 4, 5, 6, 7.
Lifestyle Changes
- The patient has been advised to check their blood sugars fasting, 2 hours after eating, and when feeling symptomatic, and to continue working on lifestyle changes including diet, regular exercise (150 min/week), and weight loss.
- The patient has been recommended to eat consistent smaller meals throughout the day, avoid carbohydrates, fats, sugary drinks/foods/candy, and eat more vegetables and lean meat.
- Regular exercise and weight loss have been shown to be beneficial in improving glycemic control and reducing the risk of cardiovascular disease in patients with T2D.
Monitoring and Referrals
- The patient has undergone a diabetic foot exam, which showed loss of sensation to bilateral heels, and has been recommended to check their feet daily.
- The patient has been referred to optometry for a diabetic yearly eye exam to monitor for any potential complications related to their T2D.
- The patient's HA1c and CMP will be rechecked, and a new glucose monitor will be sent to monitor their blood sugars.