From the Guidelines
For a patient on Jardiance 25mg, Diamicron 120mg, and metformin 2000mg with an HbA1C of 11.2% who cannot tolerate Ozempic, I would recommend adding a DPP-4 inhibitor such as sitagliptin (Januvia) 100mg once daily. This recommendation is based on the American Diabetes Association's standards of medical care in diabetes, which suggest that when monotherapy with a noninsulin agent at the maximum tolerated dose does not achieve or maintain the HbA1c target over 3 months, a second agent should be added 1.
The patient's current regimen includes metformin, which is the preferred initial pharmacologic agent for type 2 diabetes, and Jardiance, an SGLT2 inhibitor, which has been shown to improve glucose control and reduce cardiovascular risk 1. However, the patient's high HbA1C level suggests that additional therapy is needed to achieve glycemic control.
Adding a DPP-4 inhibitor such as sitagliptin can provide complementary glucose-lowering effects to the patient's current regimen, with a lower risk of gastrointestinal side effects compared to GLP-1 receptor agonists like Ozempic 1. Alternatively, if the patient has significant insulin deficiency, adding basal insulin such as insulin glargine (Lantus) could be considered, with dose adjustments based on fasting glucose readings.
Key considerations in managing this patient's diabetes include:
- Regular monitoring of blood glucose to assess the effectiveness of the new therapy and adjust the dose as needed
- Educating the patient about potential hypoglycemia symptoms and management
- Considering the patient's disease characteristics, drug preferences, and potential side effects when selecting the new therapy
- Continuously assessing and managing cardiovascular risk factors, such as dyslipidemia, hypertension, and smoking, to reduce the risk of atherosclerotic cardiovascular disease 1.
From the FDA Drug Label
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 2.3% and 2.6% and mean FPG of 63 mg/dL and 95 mg/dL, respectively. The addition of ACTOS to the sulfonylurea significantly reduced the mean HbA1c by 0.9% and 1.3% and mean FPG by 39 mg/dL and 58 mg/dL for the 15 mg and 30 mg doses, respectively. The addition of ACTOS to metformin significantly reduced the mean HbA1c by 0.8% and decreased the mean FPG by 38 mg/dL.
Another agent to add to help control her HbA1C of 11.2 could be Pioglitazone (ACTOS), as it has been shown to reduce HbA1c levels in combination with sulfonylurea and metformin.
- The patient is already on metformin 2000mg and Diamicron 120mg (a sulfonylurea), so adding Pioglitazone could be a viable option.
- The recommended dose of Pioglitazone is 30 mg or 45 mg once daily, and it has been shown to reduce HbA1c levels by 0.8% to 2.6% in clinical studies 2.
From the Research
Alternative Agents for Controlling HgA1C
Given the patient's current medication regimen and intolerance to Ozempic, another agent to consider adding to help control her HgA1C of 11.2 is sitagliptin.
- The efficacy and safety of sitagliptin added to ongoing pioglitazone therapy in patients with type 2 diabetes have been assessed in a 24-week, multicenter, randomized, double-blind, placebo-controlled, parallel-group study 3.
- Sitagliptin has been shown to be effective in reducing HbA1c levels when used as add-on therapy to pioglitazone, with a mean reduction of 0.7-1.4% from a baseline of 8-8.5% 4, 5.
- The combination of sitagliptin and pioglitazone has been well tolerated, with no increased risk of hypoglycemia and similar or slightly more weight gain than pioglitazone alone 4, 5.
- Sitagliptin is a DPP-4 inhibitor that enhances the action of incretin hormones, increasing active levels of GLP-1 and GIP, and has been shown to be efficacious and safe in clinical studies 6, 7.
- Sitagliptin has a neutral effect on body weight and does not cause a higher rate of hypoglycemia in comparison to metformin or placebo 6, 7.