From the Guidelines
The patient's current medication regimen should be continued with an adjustment to the insulin component, increasing the Degludec dose by 2-4 units daily, as the HbA1c level of >14% indicates poor glycemic control, requiring intensification of the insulin regimen. The patient should maintain metformin 1000 mg twice daily and glipizide 10 mg once daily. This multi-modal approach is appropriate for patients with severely elevated HbA1c levels who need comprehensive glycemic management, as it targets different aspects of glucose regulation: metformin decreases hepatic glucose production and improves insulin sensitivity, glipizide stimulates pancreatic insulin secretion, and Degludec provides long-acting basal insulin coverage 1.
When increasing Degludec, the patient should monitor blood glucose levels closely for the first few days after the dose change to ensure they're not experiencing hypoglycemia. According to the most recent guidelines, treatment intensification requires purposeful selection of medications in alignment with multiple individualized person-centered treatment goals simultaneously, and the addition of basal insulin, such as Degludec, is recommended when A1C levels are above target 1.
The combination approach is supported by the latest evidence, which suggests that each new class of oral noninsulin agents, when added to metformin, generally lowers A1C by approximately 0.7–1.0% (8–11 mmol/mol), and the addition of GLP-1 RAs or dual GIP and GLP-1 RA to metformin usually results in 1 to 2% lowering of A1C 1. However, in this case, the focus is on adjusting the insulin component to achieve better glycemic control, as indicated by the patient's elevated HbA1c level.
Key considerations in this adjustment include:
- Monitoring for hypoglycemia after increasing the Degludec dose
- Maintaining metformin and glipizide as part of the comprehensive treatment plan
- Recognizing the importance of individualized treatment goals and the potential need for further adjustments based on the patient's response to the current regimen 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Medication Management
- The patient is currently taking metformin 1000 mg PO BID and glipizide 10 mg PO daily, with a last HbA1c level of >14, indicating poor glycemic control 2.
- The patient is also taking degleudec 22 units daily, which can be increased by 2-4 units to improve glycemic control.
- Metformin is a commonly used medication for the management of type 2 diabetes, and its mechanism of action is based on reducing glucose production in the liver, decreasing insulin resistance, and increasing insulin sensitivity 3, 4.
- Glipizide is a sulfonylurea that stimulates insulin release from the pancreas, and its addition to metformin has been shown to improve glycemic control in patients with type 2 diabetes 5.
Treatment Options
- The current treatment regimen includes metformin and glipizide, which have been shown to be effective in improving glycemic control in patients with type 2 diabetes 5, 6.
- The addition of degleudec, a basal insulin, can help to improve glycemic control by reducing glucose levels throughout the day.
- Other treatment options, such as exenatide and vildagliptin, have been shown to be effective in improving glycemic control and insulin sensitivity in patients with type 2 diabetes 6.
Glycemic Control
- HbA1c is a measure of long-term glycemic control, and a level of >14 indicates poor control 2.
- The goal of treatment is to achieve an HbA1c level of <7%, which can be achieved through a combination of medication, diet, and exercise.
- Regular monitoring of HbA1c levels is necessary to assess the effectiveness of treatment and make adjustments as needed 2.