What treatment is recommended for a patient with hyperglycemia (elevated glucose level of 121) and an Hemoglobin A1c (HbA1c) level of 6.9?

From the Guidelines

A glucose level of 121 mg/dL and an A1C of 6.9% indicate prediabetes or early type 2 diabetes that requires treatment, and I recommend starting with lifestyle modifications and metformin as the first-line treatment. According to the American Diabetes Association guidelines 1, lifestyle modifications, including physical activity and weight loss, should be initiated in newly diagnosed patients who are overweight or obese.

• The patient should be counseled to lose at least 5% of their body weight.
• Metformin therapy should be added at or soon after diagnosis if lifestyle efforts are not sufficient to maintain or achieve glycemic goals.
• Metformin is the preferred initial pharmacologic agent due to its efficacy, safety, and potential to reduce the risk of cardiovascular events and death.
• The initial dose of metformin should be 500 mg once daily with dinner for one week, then increased to 500 mg twice daily, and can be gradually increased to 1000 mg twice daily as needed and tolerated.
• Regular blood glucose monitoring is important, with a target fasting glucose below 100 mg/dL and A1C below 7% as recommended by the American College of Physicians 1.
• Follow-up with the healthcare provider in 3 months is necessary to reassess the A1C and adjust treatment if needed.
• Staying hydrated and monitoring kidney function while on metformin is also important, as metformin can be continued in patients with declining renal function down to a glomerular filtration rate (GFR) of 30 to 45 mL/min, although the dose should be reduced 1.

From the FDA Drug Label

Although most patients in the previously-treated group had a decrease from baseline in HbA1c and FPG with ACTOS, in many cases the values did not return to screening levels by the end of the study. For patients who had not been previously treated with antidiabetic medication, mean values at screening were 10.1% for HbA1c and 238 mg/dL for FPG. For patients who had been previously treated with antidiabetic medication, mean values at screening were 9.4% for HbA1c and 216 mg/dL for FPG. Compared with placebo, treatment with ACTOS titrated to a final dose of 30 mg and 45 mg resulted in reductions from baseline in mean HbA1c of 1.3% and 1.4% and mean FPG of 55 mg/dL and 60 mg/dL, respectively.

The patient's glucose level is 121 and A1c is 6.9. Treatment with pioglitazone (ACTOS) may be considered, as it has been shown to reduce HbA1c and FPG levels in patients with type 2 diabetes. However, the decision to treat should be based on individual patient factors and clinical judgment.

• Key considerations:
  • The patient's A1c level is 6.9, which is close to the target range for many patients with diabetes.
  • The patient's glucose level is 121, which is slightly elevated.
  • Pioglitazone (ACTOS) has been shown to be effective in reducing HbA1c and FPG levels in patients with type 2 diabetes, but may not be suitable for all patients. 2

From the Research

Glucose and HbA1c Levels

• The given glucose level is 121 and the HbA1c level is 6.9, which indicates that the patient's blood glucose levels are not within the normal range 3.
• According to the study published in the Journal of laboratory physicians, there is a statistically significant positive correlation between random blood sugar (RBS) and estimated average glucose (eAG) values for patients with HbA1c levels between 6.5 to 9% 4.

Treatment Options

• The study published in Endocrine practice suggests that adding pioglitazone or sitagliptin to patients with type 2 diabetes who are insufficiently controlled with metformin and a sulfonylurea can be an effective treatment option 5.
• Another study published in Vascular health and risk management found that the combination of DPP-4 inhibitors and pioglitazone can be a useful therapeutic approach in patients with type 2 diabetes who cannot tolerate metformin or a sulfonylurea 6.
• The study published in Diabetes, obesity & metabolism found that lower baseline HbA1c levels are associated with a higher likelihood of reaching the target HbA1c level of ≤7.0% with structured titration of insulin glargine in type 2 diabetes 7.

Remission in Type 2 Diabetes

• The Consensus Report published in Diabetes care proposes that remission in type 2 diabetes can be defined as an HbA1c level <6.5% measured at least 3 months after cessation of glucose-lowering pharmacotherapy 3.
• However, the report also notes that the long-term risks and benefits of achieving remission are not well understood and require further study.

Considerations for Treatment

• When considering treatment options, it is essential to take into account the patient's baseline HbA1c level, as well as their individual characteristics and medical history 5, 6, 7.
• The treatment plan should be tailored to the patient's specific needs and should aim to achieve optimal glycemic control while minimizing the risk of hypoglycemia and other adverse events 4, 5, 6, 7.