In an 85‑year‑old woman with hemoglobin A1c 8.0% who is taking metformin 500 mg twice daily and empagliflozin (Jardiance) 10 mg daily, is this glycemic target acceptable and should the current regimen be continued or intensified?

A1C 8.0% in an 85-Year-Old on Metformin and Jardiance: Current Regimen is Acceptable

For this 85-year-old woman with A1C 8.0% on metformin 500mg BID and empagliflozin 10mg daily, the current glycemic target is acceptable and the regimen should be continued without intensification. 1, 2

Evidence-Based Glycemic Target for This Patient

The appropriate A1C target for an 85-year-old patient is 8.0-8.5% or higher, not the standard <7% used in younger adults. 1, 2, 3 This patient's current A1C of 8.0% falls within the recommended range and represents appropriate glycemic control for her age.

Age-Specific Target Rationale

• For older adults aged ≥80 years with complex or intermediate health status, the American Diabetes Association recommends an A1C target of 8.0% (64 mmol/mol), with targets potentially extending to 8.5% (69 mmol/mol) or higher for those with very complex health or limited life expectancy. 1, 2

• Adults ≥80 years have more than twice the emergency department visit rate and nearly five times the hospitalization rate for insulin-related hypoglycemia compared to middle-aged adults. 2, 3

• Targeting A1C <7% in elderly patients increases hypoglycemia risk without providing reductions in cardiovascular events or mortality. 2

• Microvascular complications require years to manifest benefit from tight control, making aggressive targets inappropriate when life expectancy may be limited. 2

Current Medication Regimen Assessment

The combination of metformin 500mg BID and empagliflozin 10mg daily is appropriate and should be continued. 1, 3

Metformin Component

• Metformin remains first-line therapy for older adults with low hypoglycemia risk and should be maintained if tolerated and renal function permits (eGFR ≥30 mL/min/1.73 m²). 3, 4

• The current dose of 500mg BID is conservative and appropriate for an 85-year-old, minimizing gastrointestinal side effects while providing glycemic benefit. 3

Empagliflozin (Jardiance) Component

• SGLT2 inhibitors like empagliflozin have demonstrated cardiovascular and renal benefits beyond glycemic control, making them valuable in older adults with or at risk for cardiovascular disease. 1

• Empagliflozin 10mg daily provides meaningful A1C reduction (approximately 0.5-0.7%) with low hypoglycemia risk when combined with metformin. 5, 6, 7

• The combination of metformin and empagliflozin addresses multiple pathophysiologic defects without requiring complex dosing schedules. 5

Why Intensification is NOT Recommended

Do not intensify therapy in this patient. Intensification would increase treatment burden and hypoglycemia risk without meaningful benefit. 1, 2

Critical Safety Considerations

• Targeting A1C <7% in this 85-year-old would increase hypoglycemia risk without providing mortality benefit. 1, 2

• Overtreatment of diabetes is common in older adults and should be avoided; tight glycemic control in elderly patients with multiple medical conditions is considered overtreatment. 1

• The American College of Physicians specifically recommends that physician performance measures should not include specific A1C targets for adults aged ≥80 years, recognizing that the balance of benefits and harms shifts in this population. 2

Treatment Burden Considerations

• Adding additional medications (such as sulfonylureas, DPP-4 inhibitors, or insulin) would increase regimen complexity, cost, and side effect risk without appropriate benefit at this A1C level. 1

• Sulfonylureas should be avoided in older adults due to high hypoglycemia risk and should never be combined with insulin. 3

• Intensive insulin regimens (basal-bolus or multiple daily injections) are inappropriate unless absolutely necessary due to increased hypoglycemia risk and complexity. 3

Monitoring and Follow-Up Plan

Continue current regimen with appropriate monitoring intervals. 1, 2, 3

Monitoring Schedule

• Check A1C every 6 months if stable and meeting the individualized target of 8.0-8.5%. 1, 2

• Monitor renal function periodically to ensure metformin safety (maintain if eGFR ≥30 mL/min/1.73 m²). 3, 4

• Assess for hypoglycemia symptoms at each visit, recognizing that older adults often present atypically with confusion or dizziness rather than classic adrenergic symptoms. 2, 3

Functional Assessment

• Evaluate cognitive function and functional status at each visit, as these factors influence appropriate glycemic targets and treatment decisions. 1, 2

• Assess self-management capabilities and caregiver support to ensure the patient can safely manage her current regimen. 1

• Monitor for geriatric syndromes (falls, frailty, polypharmacy) that may influence treatment decisions. 2

When to Consider Deintensification (Not Intensification)

If A1C falls below 7.0%, consider reducing therapy rather than maintaining current regimen. 1, 2

• A1C levels below 6.5% are associated with increased mortality in older adults without additional benefit. 1, 2

• Deintensification should be considered if severe or recurrent hypoglycemia occurs, cognitive or functional decline develops, or the patient experiences pain/discomfort from treatment. 3

• If deintensification becomes necessary, empagliflozin could be reduced to 10mg every other day or discontinued before adjusting metformin, given metformin's established safety profile and low hypoglycemia risk. 3

Common Pitfalls to Avoid

• Do not apply standard adult diabetes targets (<7% A1C) to this 85-year-old patient, as doing so increases harm without benefit. 2

• Do not add sulfonylureas due to their high hypoglycemia risk in elderly patients. 1, 3

• Do not initiate insulin solely based on the A1C number without accounting for age-appropriate targets. 2

• Do not assume higher A1C targets alone prevent hypoglycemia—medication selection (avoiding sulfonylureas and minimizing insulin) is more important than the target itself. 2