How to optimize a 67-year-old female patient with type 2 diabetes mellitus (T2DM) and elevated hemoglobin A1c (HbA1c) levels, currently on Jardiance (empagliflozin) 10mg, Soliqua (insulin glargine and lixisenatide) 50 units once daily, and repaglinide 1mg three times a day with meals?

From the Guidelines

To optimize this 67-year-old female with poorly controlled type 2 diabetes (A1c 9.6%), I recommend setting an A1c target of 7-8% and intensifying her regimen by continuing Soliqua 50 units daily and replacing repaglinide with a once-daily DPP-4 inhibitor such as sitagliptin 50 mg daily, considering her kidney function and potential for hypoglycemia 1.

Medication Adjustments

• Continue Soliqua 50 units daily to maintain basal insulin coverage and GLP-1 receptor agonist benefits.
• Replace repaglinide with sitagliptin 50 mg daily, as DPP-4 inhibitors offer better postprandial glucose control with less hypoglycemia risk, which is particularly important in an older patient 1.
• Consider reducing the dose of Jardiance to 10 mg daily, as the patient's kidney function should be assessed before making any changes to SGLT2 inhibitors, and dose adjustments may be necessary based on eGFR levels 1.

Lifestyle Modifications

• Implement continuous glucose monitoring if possible to closely monitor glucose levels and adjust the treatment plan accordingly.
• Set an A1c target of 7-8% given her age and comorbidities, as this range is recommended for most patients with type 2 diabetes 1.
• Initiate statin therapy if not already prescribed, as it is recommended for patients with diabetes to reduce cardiovascular risk.
• Schedule follow-up in 3 months to reassess her A1c and adjust the treatment plan as needed.
• Emphasize lifestyle modifications, including dietary counseling with carbohydrate counting and moderate physical activity, to balance improved glycemic control with reduced hypoglycemia risk while simplifying her medication regimen 1.

Key Considerations

• The patient's kidney function should be assessed before making any changes to her medication regimen, particularly with regards to SGLT2 inhibitors and DPP-4 inhibitors 1.
• The risk of hypoglycemia should be carefully considered when adjusting her medication regimen, and the patient should be educated on the signs and symptoms of hypoglycemia and how to manage it 1.
• The importance of continuous glucose monitoring and regular follow-up should be emphasized to closely monitor the patient's glucose levels and adjust the treatment plan accordingly.

From the FDA Drug Label

In patients with type 2 diabetes, treatment with JARDIANCE reduced hemoglobin A1c (HbA1c), compared to placebo The reduction in HbA1c for JARDIANCE compared with placebo was observed across subgroups including gender, race, geographic region, baseline BMI and duration of disease. Drugs That May Increase the Risk of Hypoglycemia Drugs:Antidiabetic agents, ACE inhibitors, angiotensin II receptor blocking agents, disopyramide, fibrates, fluoxetine, monoamine oxidase inhibitors, pentoxifylline, pramlintide, salicylates, somatostatin analogs (e.g., octreotide), and sulfonamide antibiotics. Intervention:Dose reductions and increased frequency of glucose monitoring may be required when SOLIQUA 100/33 is coadministered with these drugs.

The patient is currently taking Jardiance 10, Soliqua 50U, and repaglinide 1 mg TID. To optimize the patient's treatment, consider the following:

• Dose adjustment: The patient's current HbA1c is 9.6, which is above the target range. Consider increasing the dose of Jardiance to 25 mg or adding another antidiabetic agent.
• Glucose monitoring: Increase the frequency of glucose monitoring to prevent hypoglycemia when coadministering Soliqua 100/33 with other antidiabetic agents.
• Medication interactions: Be aware of potential interactions between Soliqua 100/33 and other medications, such as antidiabetic agents, ACE inhibitors, and salicylates, which may increase the risk of hypoglycemia.
• Renal function: Monitor the patient's renal function, as Jardiance has been studied in patients with mild or moderate renal impairment.
• Weight management: Consider the patient's weight, as Jardiance has been shown to reduce body weight in clinical trials.
• Blood pressure management: Monitor the patient's blood pressure, as Jardiance has been shown to reduce systolic blood pressure in clinical trials. The patient's treatment plan should be individualized based on their specific needs and medical history. Consult with the patient's healthcare provider to determine the best course of treatment 2 3.

From the Research

Optimizing Treatment for a 67-year-old Female Patient with Type 2 Diabetes

To optimize treatment for the patient, several factors need to be considered, including the current medication regimen, the patient's A1C level, and potential treatment intensification options.

• Current Medication Regimen: The patient is currently taking Jardiance 10mg, Soliqua 50U once daily, and repaglinide 1mg TID with meals. This regimen includes a combination of oral and injectable medications, which may contribute to medication regimen complexity 4.
• A1C Level: The patient's A1C level is 9.6%, indicating poor glycemic control. Studies have shown that patients with A1C levels ≥9% may require treatment intensification, including the use of injectable medications such as glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and basal insulin 5, 6.
• Treatment Intensification Options: Treatment intensification options for the patient may include the use of a fixed-ratio combination of basal insulin and a GLP-1 RA, such as iGlarLixi. Studies have shown that iGlarLixi can provide significant improvements in glycemic control, including reductions in A1C levels and weight loss, with a lower risk of hypoglycemia and gastrointestinal adverse events compared to sequential administration of basal insulin and a GLP-1 RA 6, 7, 8.

Potential Benefits of iGlarLixi

The use of iGlarLixi may offer several potential benefits for the patient, including:

• Improved Glycemic Control: iGlarLixi has been shown to provide significant improvements in glycemic control, including reductions in A1C levels and weight loss 6, 7, 8.
• Simplified Medication Regimen: iGlarLixi is a fixed-ratio combination of basal insulin and a GLP-1 RA, which may simplify the patient's medication regimen and reduce medication regimen complexity 4.
• Lower Risk of Hypoglycemia and Gastrointestinal Adverse Events: iGlarLixi has been shown to have a lower risk of hypoglycemia and gastrointestinal adverse events compared to sequential administration of basal insulin and a GLP-1 RA 6, 7, 8.