From the Guidelines
I recommend adding a GLP-1 receptor agonist such as semaglutide (Ozempic) starting at 0.25 mg subcutaneously once weekly for 4 weeks, then increasing to 0.5 mg weekly, with potential further titration to 1 mg weekly if needed. This patient has inadequately controlled type 2 diabetes with an A1c of 9.0% despite being on metformin and an SGLT-2 inhibitor (Jardiance) 1. GLP-1 receptor agonists are particularly appropriate here as they provide robust A1c reduction (typically 1-2%), promote weight loss (beneficial even though BMI is normal at 23.9), and offer cardiovascular benefits. They work by increasing glucose-dependent insulin secretion, suppressing glucagon release, slowing gastric emptying, and increasing satiety.
Some key points to consider when adding a GLP-1 receptor agonist include:
- Common side effects include nausea, vomiting, and diarrhea, which typically improve with continued use.
- The patient should be monitored for gastrointestinal side effects and hypoglycemia, though the risk is low with this combination.
- If GLP-1 therapy is not tolerated or contraindicated, a DPP-4 inhibitor like sitagliptin or basal insulin therapy would be reasonable alternatives 1.
- 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.
Given the patient's current regimen and the need for further glycemic control, the addition of a GLP-1 receptor agonist is a logical next step, supported by recent guidelines and evidence 1.
From the FDA Drug Label
At Week 24, JARDIANCE 10 mg or 25 mg used in combination with linagliptin 5 mg provided statistically significant improvement in HbA1c (p-value <0.0001) and FPG (p-value <0. 001) compared to the individual components in patients who had been inadequately controlled on metformin.
The patient is already on metformin and Jardiance (empagliflozin), and the current A1c is 9.0, indicating inadequate glycemic control.
- Next step: Consider adding linagliptin to the patient's current regimen, as the combination of JARDIANCE and linagliptin has been shown to provide statistically significant improvement in HbA1c and FPG compared to the individual components in patients inadequately controlled on metformin 2.
From the Research
Patient Profile
- 50-year-old male with type 2 diabetes (DM2)
- Current A1c: 9.0
- Medications: metformin 2g per day, Jardiance 12.5mg qd, atorvastatin, and losartan
- BMI: 23.9
Treatment Considerations
- The patient's current A1c level is above the target range, indicating the need for adjustment to their treatment plan 3
- Studies have shown that patients with suboptimal glycemic control may benefit from intensification of treatment, including the addition of new medications or adjustment of existing medications 3, 4
- The patient is already on metformin, which has been shown to improve glycemic control and lipid concentrations in patients with type 2 diabetes 5
Potential Next Steps
- Consider adding a dipeptidyl peptidase-4 (DPP-4) inhibitor, such as sitagliptin, to the patient's treatment plan, as it has been shown to have beneficial effects on lipid profiles when combined with metformin 6
- Alternatively, consider adjusting the patient's existing medications or adding a new medication, such as a sulfonylurea or a glucagon-like peptide-1 (GLP-1) receptor agonist, to improve glycemic control
- Self-monitoring of blood glucose (SMBG) is an essential strategy for improving glycemic control, and patients should be educated on proper technique and frequency of monitoring 7