From the Guidelines
This patient's medication regimen requires immediate optimization to improve glycemic control, and I strongly recommend discontinuing Janumet XR and adjusting the insulin doses based on the latest guidelines from the 2025 Diabetes Care standards 1. The patient's current A1c of 11.2% indicates poor glycemic control, and the combination of insulin (Lantus and Humalog 50/50) and Janumet XR (sitagliptin-metformin) creates unnecessary overlap and increases hypoglycemia risk.
- The patient should continue Lantus (basal insulin) and Humalog (bolus insulin) with appropriate dose titration based on blood glucose monitoring, starting with a basal insulin dose of 10 units per day or 0.1-0.2 units/kg per day, as recommended by the 2025 Diabetes Care standards 1.
- The hydrochlorothiazide may worsen glucose control and should be evaluated for possible replacement with a more diabetes-friendly alternative like an ACE inhibitor (the patient is already on lisinopril) or calcium channel blocker.
- The high A1c indicates poor glycemic control despite multiple medications, suggesting the need for comprehensive diabetes management review, including diet, exercise, medication adherence, and proper insulin administration technique.
- The patient should be referred to an endocrinologist and diabetes educator for intensive management, and consideration should be given to adding a GLP-1 RA or dual GIP and GLP-1 RA to the treatment regimen if the A1c remains above goal, as recommended by the 2025 Diabetes Care standards 1. Key considerations for insulin therapy include:
- Basal insulin may be initiated at 10 units or 0.1 to 0.2 units/kg of body weight, as stated in the 2016 Annals of Internal Medicine study 1.
- Timely dose titration is important, and adjustment of both basal and prandial insulins should be based on SMBG levels, as recommended by the 2016 Annals of Internal Medicine study 1.
From the Research
Medication Regimen
The patient is currently taking a combination of medications, including:
- Apixaban (ELIQUIS) 5 mg tablet
- Atorvastatin (LIPITOR) 40 mg tablet
- Gabapentin (NEURONTIN) 300 mg capsule
- Hydrochlorothiazide (HYDRODIURIL) 25 mg tablet
- Insulin glargine (Lantus Solostar U-100 Insulin) 100 unit/mL (3 mL) injection pen
- Insulin lispro protamine-insulin lispro (HumaLOG 50/50 KwikPen) 100 unit/mL (50-50) injection pen
- Levothyroxine (SYNTHROID, LEVOTHROID) 175 mcg tablet
- Lisinopril (PRINIVIL, ZESTRIL) 40 mg tablet
- Pantoprazole (PROTONIX) 40 mg EC tablet
- Ropinirole (REQUIP) 0.5 mg tablet
- Sitagliptin phos-metformin (Janumet XR) 100-1,000 mg tablet, ER multiphase 24 hr
Glycemic Control
The patient has a high A1c level of 11.2, indicating poor glycemic control. According to 2, increasing hemoglobin A1c time in range reduces adverse health outcomes in older adults with diabetes.
Treatment Options
Studies have shown that combination therapy with SGLT2 inhibitors and GLP-1 receptor agonists can improve glycemic control and reduce cardiovascular risk factors in patients with type 2 diabetes 3. Additionally, insulin therapy with insulin glargine and insulin lispro can be effective in achieving glycemic control 4, 5.
Lifestyle Modifications
Lifestyle modifications, such as calorie restriction, increased physical activity, and self-monitoring, can also be beneficial in improving glycemic control and reducing the risk of diabetes-related complications 6.
Key Considerations
- The patient's current medication regimen and glycemic control status should be carefully evaluated to determine the best course of treatment.
- Combination therapy with SGLT2 inhibitors and GLP-1 receptor agonists may be considered to improve glycemic control and reduce cardiovascular risk factors.
- Lifestyle modifications, such as diet and exercise, should be encouraged to improve overall health and reduce the risk of diabetes-related complications.