From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
For a type 2 diabetic with an A1C of 11%, I recommend a three-medication regimen of metformin 1000mg twice daily, an SGLT-2 inhibitor such as empagliflozin 10mg daily, and a GLP-1 receptor agonist like semaglutide (weekly injection starting at 0.25mg and titrating up to 1mg). This combination is supported by the most recent and highest quality study, which demonstrated the efficacy and safety of combining SGLT-2 inhibitors and GLP-1 receptor agonists in patients with type 2 diabetes mellitus 1.
Rationale for Medication Choice
- Metformin is chosen for its ability to decrease hepatic glucose production and improve insulin sensitivity, as demonstrated in a study where metformin supported the antidiabetic effect of an SGLT2 inhibitor by suppressing endogenous glucose production in diabetic mice 2.
- An SGLT-2 inhibitor such as empagliflozin is selected for its role in promoting urinary glucose excretion and offering cardiovascular and renal benefits, as shown in a study where SGLT2i exerted cardiorenal protection among people at high CV risk 3.
- A GLP-1 receptor agonist like semaglutide is included for its ability to stimulate insulin secretion, suppress glucagon, slow gastric emptying, and promote weight loss, as discussed in a review of GLP-1 receptor agonists in the treatment of type 2 diabetes 4.
Implementation and Monitoring
Start with metformin and gradually add the other medications over 4-8 weeks to minimize side effects. Regular blood glucose monitoring is essential during initiation, and the patient should be aware of potential side effects including gastrointestinal issues with metformin and GLP-1 agonists, and urinary tract infections with SGLT-2 inhibitors. Lifestyle modifications including diet and exercise remain crucial alongside medication therapy.
Considerations for Morbidity, Mortality, and Quality of Life
This aggressive approach is necessary for an A1C of 11%, which indicates severe hyperglycemia. The chosen combination addresses multiple aspects of type 2 diabetes and has been shown to improve glycemic control, reduce body weight, and offer cardiovascular and renal benefits, ultimately improving morbidity, mortality, and quality of life for patients with type 2 diabetes 5, 1.