From the Guidelines
The current regimen of Janumet XR 50-1000 mg twice daily and Jardiance 10 mg daily is not adequately controlling this patient's diabetes, as evidenced by the significantly elevated hemoglobin A1c of 11.8% (well above the target of <7%), and therefore, intensification of the regimen is necessary to reduce the risk of diabetes complications. According to the most recent guidelines, when the HbA1c level is significantly elevated, as in this case, treatment intensification should not be delayed 1. The patient's current medications, Janumet XR (containing sitagliptin and metformin) and Jardiance (containing empagliflozin), are appropriate choices but insufficient at controlling this level of hyperglycemia.
Key Considerations for Treatment Intensification
- The high A1c indicates average blood glucose levels around 298 mg/dL, putting the patient at significant risk for diabetes complications including cardiovascular disease, neuropathy, nephropathy, and retinopathy.
- Before changing medications, it's essential to assess adherence to the current regimen, dietary habits, and physical activity levels, as these factors significantly impact glycemic control.
- The addition of a GLP-1 receptor agonist like semaglutide (Ozempic) or dulaglutide (Trulicity) could be beneficial, as these agents have demonstrated efficacy in lowering HbA1c levels and have additional benefits such as weight reduction and reduced risk of hypoglycemia 1.
- Alternatively, considering insulin therapy or switching to a combination of insulin plus oral medications could also be effective in achieving better glycemic control.
Recommendations
- Intensify the current regimen by adding a third medication, specifically a GLP-1 receptor agonist, or consider insulin therapy to promptly reduce the risks associated with high blood glucose levels.
- Assess and address any barriers to adherence, dietary habits, and physical activity levels to optimize glycemic control.
- Monitor the patient's response to the intensified regimen and adjust as necessary to achieve and maintain an HbA1c level below 7%.
From the Research
Patient's Current Regimen
The patient is currently taking Janumet XR50-1000 bid and Jardiance 10mg daily.
- Janumet XR contains sitagliptin and metformin, which are used to improve glycemic control in patients with type 2 diabetes 2.
- Jardiance contains empagliflozin, an SGLT2 inhibitor that has been shown to have beneficial effects on glycemic control, body weight, and cardiovascular risk factors in patients with type 2 diabetes 3.
Efficacy of the Regimen
The patient's hemoglobin A1c (HbA1c) level is 11.8, indicating poor glycemic control.
- Studies have shown that combination therapy with an SGLT2 inhibitor and a GLP-1 receptor agonist can be effective in improving glycemic control and reducing body weight in patients with type 2 diabetes 3.
- However, the patient is not currently taking a GLP-1 receptor agonist, but rather sitagliptin, which is a DPP-4 inhibitor.
- A study comparing oral semaglutide (a GLP-1 receptor agonist) to sitagliptin found that semaglutide resulted in significantly greater reductions in HbA1c and body weight 2.
Considerations for Treatment
When considering treatment options for the patient, it is essential to take into account the potential benefits and risks of different therapies.
- The patient's high HbA1c level indicates a need for improved glycemic control, and combination therapy with an SGLT2 inhibitor and a GLP-1 receptor agonist may be a viable option 3.
- However, the patient's current regimen includes sitagliptin, which may not be as effective as semaglutide in reducing HbA1c and body weight 2.
- Further research is needed to determine the best course of treatment for this patient, and consultation with a healthcare professional is recommended to determine the most appropriate therapy.