Management of Type 2 Diabetes with HbA1c 8% on Jardiance (Empagliflozin)
Add a second antidiabetic agent immediately to your current Jardiance regimen, with metformin as the preferred choice if not already on board, or consider adding a GLP-1 receptor agonist or DPP-4 inhibitor if metformin is contraindicated or already being used. 1
Target HbA1c and Treatment Intensification
Your target HbA1c should be between 7-8% for most adults with type 2 diabetes, which means your current level of 8% is at the upper acceptable limit but warrants treatment intensification to move toward 7% 1
The American College of Physicians specifically recommends dual-regimen combination therapy for patients with HbA1c ≥9%, but your HbA1c of 8% still indicates inadequate control on Jardiance monotherapy and requires adding a second agent 2
More stringent targets (6.5-7%) may be appropriate if you have short disease duration, long life expectancy, and no significant cardiovascular disease, but avoid targeting below 6.5% as this increases mortality risk without clinical benefit 1
Recommended Add-On Therapy Options
First Choice: Add Metformin (if not already taking it)
Metformin remains the optimal first-line agent and should be combined with Jardiance unless contraindicated by renal insufficiency or other factors 1, 2
Metformin is weight-neutral, does not cause hypoglycemia, is low-cost, and may provide cardiovascular benefits 1
The combination of empagliflozin plus metformin has demonstrated superior HbA1c reduction compared to either agent alone 3
Second Choice: Add a DPP-4 Inhibitor (Linagliptin)
The combination of empagliflozin 25 mg plus linagliptin 5 mg reduced HbA1c by 1.19% from a baseline of approximately 8%, which would bring your HbA1c well below 7% 4
This combination is particularly effective and well-tolerated, with 61.8% of patients achieving HbA1c <7% at 24 weeks 4
No increased hypoglycemia risk with this combination 4
Third Choice: Add a GLP-1 Receptor Agonist
GLP-1 receptor agonists (exenatide, liraglutide, dulaglutide) can reduce HbA1c by 2-2.5% from baseline levels around 8-10% 5
These agents provide the additional benefit of weight loss rather than weight gain 5
Particularly useful if cardiovascular disease or heart failure is present 2
What NOT to Do
Do not start insulin at your current HbA1c of 8% - insulin is reserved for HbA1c ≥10-12% with symptomatic hyperglycemia or glucose consistently >300 mg/dL 2, 5
Do not target HbA1c below 6.5% - the ACCORD trial showed increased mortality with targets <6.5%, and you should deintensify therapy if you reach this level 1
Do not delay adding a second agent - waiting for lifestyle modifications alone when HbA1c is 8% on monotherapy will prolong exposure to hyperglycemia 1
Monitoring and Follow-Up
Recheck HbA1c in 3 months after adding the second agent to assess treatment effectiveness 2
Continue Jardiance at current dose while adding the second agent 3, 6
Jardiance has demonstrated HbA1c reductions of 0.52-0.68% when used as monotherapy, so adding a complementary agent should achieve your target 3
Lifestyle Modifications (Concurrent with Medication)
Aim for at least 150 minutes per week of moderate-intensity physical activity including aerobic, resistance, and flexibility training 1
Target 5-10% weight loss if overweight, which meaningfully improves glycemic control 1
Emphasize foods high in fiber (vegetables, fruits, whole grains, legumes) and limit saturated fats and high-energy foods 1
Special Considerations
If you have stage 2 or 3 chronic kidney disease, empagliflozin 25 mg has demonstrated efficacy with HbA1c reductions of 0.42-0.68% and is well-tolerated 6
Blood pressure control, lipid management, and smoking cessation should be addressed concurrently, as these may take priority over glycemic control for preventing macrovascular complications 1
If you are over 80 years old, have limited life expectancy (<10 years), or have multiple comorbidities, a less stringent target of 7.5-8% is more appropriate to avoid treatment burden and hypoglycemia risk 1