From the Guidelines
For a 71-year-old with diabetes whose A1c remains at 8.1% despite taking Jardiance 25mg and Metformin 1500mg daily, adding basal insulin, such as insulin glargine, starting at 10 units per day, as recommended by the most recent guidelines 1, would be a good next step to achieve better glycemic control. This approach is supported by the latest standards of care in diabetes, which suggest that insulin should be considered as part of any combination medication plan when hyperglycemia is not adequately controlled with oral medications alone 1. The initiation and titration of basal analog or bedtime NPH insulin should follow an evidence-based titration algorithm, aiming to increase the dose by 2 units every 3 days to reach the fasting plasma glucose (FPG) goal without causing hypoglycemia 1. Alternatively, a GLP-1 receptor agonist like semaglutide (Ozempic) or dulaglutide (Trulicity) could be considered, as these medications have been shown to effectively lower blood sugar, promote weight loss, and provide cardiovascular benefits 1. However, the choice of medication should be individualized, taking into account the patient's specific health situation, potential side effects, and cost considerations, as well as the need to assess and manage cardiovascular risk factors, which are critical for preventing or slowing atherosclerotic cardiovascular disease (ASCVD) in persons with diabetes 1. Key considerations include:
- Starting with a low dose of insulin and titrating up to achieve the desired FPG goal
- Monitoring for hypoglycemia and adjusting the dose accordingly
- Considering the addition of other medications, such as GLP-1 receptor agonists, if insulin alone is not sufficient to achieve glycemic control
- Regularly assessing cardiovascular risk factors and managing them appropriately to prevent or slow ASCVD.
From the FDA Drug Label
In Combination with Linagliptin as Add-On to Metformin Therapy A total of 686 patients with type 2 diabetes participated in a double-blind, active-controlled study to evaluate the efficacy and safety of JARDIANCE 10 mg or 25 mg in combination with linagliptin 5 mg compared to the individual components At Week 24, JARDIANCE 10 mg or 25 mg used in combination with linagliptin 5 mg provided statistically significant improvement in HbA1c (p-value <0.0001) and FPG (p-value <0. 001) compared to the individual components in patients who had been inadequately controlled on metformin.
Adding Linagliptin to the current treatment of Jardiance 25mg and Metformin 1500mg per day may be considered, as it has been shown to provide statistically significant improvement in HbA1c and FPG in patients inadequately controlled on metformin 2.
From the Research
Current Treatment and A1c Levels
- The patient is currently taking Jardiance (Empagliflozin) 25mg and Metformin 1500mg per day, with an A1c level of 8.1% 3, 4, 5.
- The patient's current treatment regimen includes a sodium glucose cotransporter-2 (SGLT2) inhibitor, which has been shown to be effective in reducing glucose levels and improving cardiovascular outcomes in patients with type 2 diabetes 3.
Potential Additions to Current Treatment
- Considering the patient's current A1c level, adding another medication to the treatment regimen may be necessary to achieve better glycemic control.
- Options for addition to the current treatment regimen could include:
- Increasing the dose of Empagliflozin, as high-daily doses (10,25, 50mg) have been shown to be more effective in reducing HbA1c and fasting plasma glucose (FPG) compared to low doses (1,2.5, 5mg) 6.
- Adding a glucagon-like peptide-1 (GLP-1) receptor agonist, such as semaglutide, which has been shown to provide superior reductions in HbA1c and body weight compared to Empagliflozin when added to metformin monotherapy 7.
- It is essential to consider the patient's individual characteristics, such as baseline HbA1c, body weight, and blood pressure, when selecting an additional medication, as the treatment effects of Empagliflozin have been shown to vary across different categories of these factors 5.