What is the best course of action for a type 2 diabetes patient on Victoza (liraglutide) with poorly controlled diabetes, indicated by a hemoglobin A1c (HbA1c) level of severe hyperglycemia?

Management of Type 2 Diabetes with HbA1c 10.9% on Victoza Monotherapy

You must immediately add basal insulin to the current Victoza regimen, as an HbA1c of 10.9% represents severe hyperglycemia requiring urgent intensification with the most potent glucose-lowering therapy available. 1

Rationale for Immediate Insulin Initiation

The 2025 American Diabetes Association guidelines explicitly state that insulin therapy should be initiated for patients with A1C >10% (>86 mmol/mol), particularly when hyperglycemia is severe. 1 At an HbA1c of 10.9%, this patient is well above this threshold and requires the most aggressive intervention available.

• Common practice dictates starting insulin for A1C >10% to rapidly reverse glucotoxicity, which impairs beta-cell function and worsens insulin resistance. 1
• While GLP-1 receptor agonists like Victoza can be effective even at baseline A1C levels of 10-12%, evidence is scarce for individuals with baseline A1C above 10-12%, making insulin the more reliable choice. 1
• The patient is already on a GLP-1 RA (Victoza), yet remains severely uncontrolled, indicating monotherapy failure and the need for combination therapy with a more potent agent. 1

Specific Treatment Algorithm

Step 1: Initiate Basal Insulin Immediately

• Start basal insulin at 10 units daily or 0.1-0.2 units/kg body weight, administered once daily at bedtime. 2, 3
• For patients with HbA1c ≥10%, consider starting doses of 0.3-0.5 units/kg/day as total daily insulin for more aggressive initial control. 2
• Continue Victoza (liraglutide) as the combination addresses multiple pathophysiologic defects while minimizing hypoglycemia risk. 2, 3

Step 2: Add Metformin if Not Already Prescribed

• Metformin should be initiated immediately unless contraindicated (eGFR <30 mL/min/1.73 m²). 1, 3
• Metformin reduces cardiovascular events and mortality, is inexpensive, and reduces insulin requirements when used in combination therapy. 2, 3
• Start metformin at 500 mg daily and titrate up to 2000 mg/day over several weeks to minimize gastrointestinal side effects. 1

Step 3: Aggressive Insulin Titration

• Titrate basal insulin by 4 units every 3 days until fasting glucose reaches target (typically 80-130 mg/dL) without hypoglycemia. 2
• For severe hyperglycemia, more aggressive titration with 4-unit increments every 3 days is appropriate. 2
• Monitor fasting blood glucose daily during titration to guide dose adjustments. 3

Step 4: Reassess at 3 Months

• Recheck HbA1c after 3 months to determine if additional intensification is needed. 2, 3
• If HbA1c remains >7% after 3-6 months despite optimized basal insulin, add prandial insulin before the largest meal, starting with 4 units of rapid-acting insulin or 10% of the basal dose. 2

Alternative Consideration: Dual GLP-1 RA Intensification

While insulin is the guideline-recommended approach, there is evidence that severe hyperglycemia can be effectively treated with a more potent GLP-1 RA or dual GIP/GLP-1 RA, though evidence is limited for baseline A1C above 10-12%. 1

• Consider switching from Victoza (liraglutide) to semaglutide (Ozempic) 2 mg weekly, which provides superior HbA1c reduction. 2
• Research demonstrates that GLP-1 RAs can reduce HbA1c by up to 2.5% from a baseline of 10%, comparable to insulin glargine. 4
• However, this approach is less well-validated than insulin for HbA1c >10% and should only be considered if insulin is refused or contraindicated. 1

Critical Monitoring Requirements

• Check fasting blood glucose daily during insulin titration to guide dose adjustments. 3
• Reassess HbA1c every 3 months until target is achieved, then every 6 months once stable. 2, 3
• Monitor for hypoglycemia symptoms and educate the patient on recognition and treatment with 15-20 grams of rapid-acting carbohydrate. 3
• Check vitamin B12 levels periodically if metformin is initiated, as long-term use is associated with deficiency. 1

Important Caveats

• Do not delay insulin initiation waiting for oral agents or GLP-1 RAs to work—at HbA1c 10.9%, only combination therapy with insulin can reliably reduce HbA1c to target. 2
• As glucose toxicity resolves, simplifying the medication plan and potentially transitioning away from insulin to non-insulin agents is possible. 1
• Assess for symptoms of hyperglycemia (polyuria, polydipsia) or catabolism (unexpected weight loss, ketosis), which would further support immediate insulin therapy. 1
• The risk of hypoglycemia is low when combining basal insulin with GLP-1 RA due to the glucose-dependent action of liraglutide. 2, 5, 6