From the Guidelines
To address high morning blood glucose levels while taking only metformin with an A1c of 6.8, consider adding a second medication such as a GLP-1 receptor agonist or an SGLT-2 inhibitor, as the current treatment needs optimization to reduce morbidity, mortality, and improve quality of life.
Current Treatment and Goals
The patient is currently taking metformin, which is a commonly used medication for type 2 diabetes, known for its effectiveness and safety in reducing risks of microvascular complications, cardiovascular events, and death 1. However, an A1c of 6.8% indicates that the patient's average blood glucose is slightly above the target range of less than 7% for most adults with diabetes.
Lifestyle Modifications
Before adjusting the medication regimen, consider lifestyle modifications to combat high morning glucose levels, which may be due to the dawn phenomenon. This can be achieved by:
- Taking the evening metformin dose with dinner rather than at bedtime
- Avoiding carbohydrates at the evening meal
- Having a small protein snack before bed
- Considering moderate evening exercise
Adding a Second Medication
If lifestyle modifications do not help, adding a second medication to metformin should be considered. The choice of medication added to metformin is based on the clinical characteristics of the patient and their preferences, including the presence of established ASCVD or indicators of high ASCVD risk, other comorbidities, and risk for specific adverse drug effects 1. Some options for a second medication include:
- GLP-1 receptor agonists (like semaglutide or dulaglutide)
- SGLT-2 inhibitors (like empagliflozin or dapagliflozin)
Importance of Timely Intervention
It is essential to address high morning blood glucose levels promptly to prevent long-term complications associated with diabetes, such as cardiovascular disease, kidney disease, and nerve damage. The American Diabetes Association recommends initiating insulin therapy or adding a second oral agent, a GLP-1 receptor agonist, or basal insulin if noninsulin monotherapy at the maximum tolerated dose does not achieve or maintain the HbA1c target after 3 months 1.
Patient-Centered Approach
A patient-centered approach should be used to guide the choice of pharmacologic agents, taking into account the patient's preferences, values, and clinical characteristics. This approach ensures that the treatment plan is tailored to the individual's needs, promoting better adherence and outcomes.
From the Research
High Morning Blood Glucose Levels
- High morning blood glucose levels can be a challenge for individuals with type 2 diabetes, even when taking metformin, as in the case of an A1c level of 6.8.
- Research suggests that adding a GLP-1 receptor agonist to metformin can be an effective way to improve glycemic control, including reducing morning blood glucose levels 2, 3.
- GLP-1 receptor agonists have been shown to have a positive effect on HbA1c levels, with some studies demonstrating a reduction in HbA1c of up to 2.2% 3.
- The choice of GLP-1 receptor agonist may depend on individual patient factors, such as dosing frequency and potential adverse effects 4, 5.
Potential Therapeutic Approaches
- Combining metformin with a GLP-1 receptor agonist and premixed insulin may be a therapeutic approach for uncontrolled type 2 diabetes, as shown in a study where patients experienced improved glycemic control over 12 months 3.
- GLP-1 receptor agonists can help reduce blood glucose levels by augmenting hyperglycemia-induced insulin secretion, suppressing glucagon secretion, and decelerating gastric emptying 2.
- Monitoring HbA1c and blood glucose levels is crucial in guiding insulin therapy and adjusting treatment plans to achieve desired levels of glycemic control 6.
Considerations for Treatment
- When considering adding a GLP-1 receptor agonist to metformin, it is essential to evaluate the individual patient's response to treatment and potential adverse effects 4, 5.
- The effectiveness of GLP-1 receptor agonists in reducing HbA1c levels and improving glycemic control may vary depending on the specific agent and patient population 2, 3, 4.