What adjustments should be made to the medication regimen of a 65-year-old male patient with an HbA1c level of 7.1% on Ozempic (semaglutide) 1 mg, Farxiga (dapagliflozin) 10 mg, and Glipizide 5 mg to achieve better glycemic control?

Medication Adjustment for 65-Year-Old Male with A1C 7.1%

For this 65-year-old patient with an A1C of 7.1% on Ozempic 1 mg, Farxiga 10 mg, and glipizide 5 mg, discontinue the glipizide immediately, as the current regimen is achieving excellent glycemic control and the sulfonylurea adds unnecessary hypoglycemia risk without additional benefit. 1

Rationale for Glipizide Discontinuation

• The patient's A1C of 7.1% is already at or near target for this age group, with guidelines recommending 7.0-7.5% for relatively healthy older adults 1
• Glipizide (a sulfonylurea) significantly increases hypoglycemia risk and is the second leading cause of emergency room admissions due to drug side effects in patients over 65 years old 2
• The combination of Ozempic (GLP-1 RA) and Farxiga (SGLT2 inhibitor) provides robust glycemic control with minimal hypoglycemia risk, making the sulfonylurea redundant 2, 3
• Dapagliflozin (Farxiga) combined with GLP-1 therapy produces significantly less hypoglycemia (3.5%) compared to sulfonylureas (40.8%) while achieving similar glycemic efficacy 3

Current Medication Assessment

Ozempic (Semaglutide) 1 mg - MAINTAIN

• Provides excellent A1C reduction (-1.5% to -1.9%) with low hypoglycemia risk 4, 5
• Offers cardiovascular and weight benefits that are particularly valuable in this patient population 2
• The current dose of 1 mg weekly is the maximum approved dose and should be continued 4

Farxiga (Dapagliflozin) 10 mg - MAINTAIN

• Provides complementary glycemic control through insulin-independent mechanism 3
• Offers cardiovascular and renal protective benefits beyond glucose lowering 2
• Produces weight loss rather than weight gain, unlike sulfonylureas 3
• The 10 mg dose is the standard therapeutic dose and should be continued 3

Glipizide 5 mg - DISCONTINUE

• Adds hypoglycemia risk (40.8% incidence) without additional benefit given the patient is already at target A1C 3
• Causes weight gain (average +1.2 kg), counterproductive to the weight loss from Ozempic and Farxiga 3
• Sulfonylureas should be eliminated first when deintensifying therapy in older adults 1

Monitoring After Glipizide Discontinuation

• Check blood glucose more frequently for 1-2 weeks after discontinuing glipizide to ensure no rebound hyperglycemia 6
• Recheck A1C in 3 months to confirm glycemic control remains stable in the 7.0-7.5% range 1, 6
• Target fasting glucose of 100-180 mg/dL is appropriate for this age group 6
• Schedule follow-up within 2-4 weeks to assess for any changes in glycemic patterns 6

Critical Safety Considerations

• Avoid targeting A1C below 6.5% in this patient, as this increases mortality risk without additional benefit 1
• The current A1C of 7.1% represents optimal control that balances microvascular risk reduction against hypoglycemia and treatment burden 2, 1
• Continuing glipizide would increase fall risk, cognitive impairment risk, and cardiovascular event risk from hypoglycemia 6
• If A1C rises above 8.0% after glipizide discontinuation (unlikely), consider increasing Farxiga to 10 mg if not already at that dose, or adding a DPP-4 inhibitor rather than restarting sulfonylurea 2

Common Pitfalls to Avoid

• Do not add additional medications when A1C is already at target - this patient needs simplification, not intensification 2, 1
• Do not continue sulfonylureas out of inertia - the evidence strongly supports their removal in favor of newer agents with better safety profiles 1, 3
• Do not target A1C <7.0% in this age group, as the risks outweigh benefits 2, 1
• Do not wait for a hypoglycemic event before discontinuing the sulfonylurea - proactive deprescribing improves outcomes 1, 6