What is the best course of action for a patient with type 2 diabetes, currently on acarbose 50 mg, januvia (sitagliptin) 100 mg, and farxiga (dapagliflozin) 10 mg, whose HbA1c level has increased from 7.1 to 7.2 over the past three months?

Treatment Intensification Required

You should intensify this patient's diabetes regimen immediately by adding a GLP-1 receptor agonist to the current triple therapy, as the HbA1c of 7.2% exceeds the target of <7.0% and has failed to improve over three months despite adequate medication adherence. 1

Current Regimen Assessment

The patient is on a reasonable triple-drug combination addressing multiple pathophysiologic defects:

• Acarbose 50 mg (alpha-glucosidase inhibitor) - reduces postprandial glucose excursions 1
• Januvia 100 mg (DPP-4 inhibitor/sitagliptin) - enhances incretin effect 1
• Farxiga 10 mg (SGLT2 inhibitor/dapagliflozin) - promotes urinary glucose excretion and provides cardiovascular/renal protection 1

However, the static HbA1c (7.1% → 7.2%) over three months indicates this regimen is insufficient to achieve glycemic control. 2

Why Intensification is Necessary Now

• The ADA recommends HbA1c <7.0% for most patients to reduce microvascular complications (retinopathy, nephropathy, neuropathy), and this patient has not achieved this target. 1
• Waiting beyond 3 months at HbA1c above target increases complication risk and delays clinically meaningful improvements. 2
• The minimal change from 7.1% to 7.2% suggests the current regimen has reached its maximum effectiveness. 2

Recommended Treatment Intensification

Add a GLP-1 receptor agonist (such as liraglutide, semaglutide, or dulaglutide) to the current regimen:

• GLP-1 receptor agonists provide HbA1c reduction of 0.6-0.8% when added to existing therapy, which would bring this patient to approximately 6.4-6.6%. 2
• They offer superior cardiovascular benefits compared to other glucose-lowering agents, with demonstrated reductions in CV death, myocardial infarction, and stroke in high-risk patients. 1
• GLP-1 receptor agonists cause weight loss rather than weight gain, an important advantage over insulin or sulfonylureas. 3
• They have minimal hypoglycemia risk when used without sulfonylureas or insulin. 2

The combination of metformin-equivalent therapy (your patient has SGLT2i + DPP-4i), plus a GLP-1 receptor agonist addresses multiple pathophysiologic defects while minimizing adverse effects. 2

Alternative: Consider Basal Insulin

If GLP-1 receptor agonists are contraindicated, not tolerated, or not covered by insurance:

• Initiate basal insulin at 10 units daily or 0.1-0.2 units/kg/day, titrating by 2 units every 3 days until fasting glucose reaches target (<130 mg/dL). 2
• However, insulin carries higher hypoglycemia risk and causes weight gain, making it a less preferred option at this HbA1c level. 3

Important Caveats

Do not simply increase acarbose dose - the patient is already on a low dose (50 mg), but acarbose typically provides only modest HbA1c reductions (0.5-0.8%) and is limited by gastrointestinal side effects at higher doses. 1

Maintain all current medications - each addresses different pathophysiologic mechanisms:

• Continue Farxiga for cardiovascular/renal protection (reduces CV death and HF hospitalization). 1
• Continue Januvia as it complements the other agents without significant adverse effects. 1
• Continue acarbose if tolerated, as it specifically targets postprandial glucose. 1

Monitoring Plan

• Recheck HbA1c in 3 months after adding the GLP-1 receptor agonist to assess treatment effectiveness. 2
• Monitor renal function periodically - both Farxiga and metformin (if patient is on it) require dose adjustment if eGFR declines below 45 mL/min/1.73 m². 1
• If HbA1c remains >7% after 3-6 months despite the GLP-1 receptor agonist addition, further intensification with basal insulin will be necessary. 2

Special Considerations for Target Individualization

While the general target is <7%, consider a less stringent target of 7.5-8.0% only if this patient has:

• History of severe hypoglycemia 1
• Limited life expectancy (<10 years) 1
• Advanced complications or extensive comorbidities 1
• Advanced chronic kidney disease (stages 4-5) on insulin or sulfonylureas 2

However, none of these appear to apply based on the information provided, so the standard target of <7% is appropriate. 1