From the Guidelines
I strongly recommend adjusting your diabetes management plan to address the elevated HbA1c of 10.0%, which has increased from 8.4%, by optimizing your current medications and monitoring regimen. First, continue taking Synjardy 5-1000 mg twice daily as prescribed. For your Trulicity, consider increasing the dose from 0.75 mg to 1.5 mg weekly, as this higher dose often provides better glucose control, according to the properties of GLP-1 receptor agonists 1. Regarding your insulin, I suggest adjusting the doses based on the guidelines for basal analog or bedtime NPH insulin initiation and titration, which recommend starting with 10 units per day or 0.1-0.2 units/kg per day and titrating to reach the FPG goal without hypoglycemia 1.
Given your current regimen of Lantus 10 units in the morning and 40 units in the evening, and considering the recent guidelines for insulin titration 1, it is crucial to assess the adequacy of your insulin dose and consider clinical signals for overbasalization, such as elevated bedtime-to-morning and/or postprandial-to-preprandial differential, hypoglycemia, or high glucose variability. Since your A1C is above goal and you are already on a GLP-1 RA (Trulicity), consider optimizing the dose of Trulicity and adjusting your insulin regimen according to the evidence-based titration algorithm, which may include increasing the morning dose of Lantus to achieve better glucose control while monitoring for signs of overbasalization or hypoglycemia 1.
Additionally, start monitoring your blood glucose levels more frequently—at least 3-4 times daily—and keep a detailed log of readings, meals, and physical activity. This elevated HbA1c indicates your average blood glucose has been significantly above the target range, and these adjustments aim to lower your blood glucose levels gradually and safely. The combination of optimized basal insulin, GLP-1 therapy (Trulicity), and continued SGLT2 inhibitor/metformin therapy (Synjardy) addresses multiple aspects of glucose regulation. Schedule a follow-up appointment in 4-6 weeks to reassess your response to these changes and make further adjustments if needed, considering the latest guidelines for pharmacologic approaches to glycemic treatment 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
HbA1c Levels and Medication
- The patient's HbA1c level has increased from 8.4 to 10.0, indicating a need for adjustment in their medication regimen 2.
- The patient is currently taking Synjardy (5-1000 mg tablet) BID daily, Trulicty (0.75 mg SC weekly), and Lantus (10 units in the morning and 40 units in the evening).
Adjusting Medication Regimens
- A study comparing the addition of albiglutide, a weekly GLP-1 receptor agonist, to thrice-daily prandial insulin lispro in patients with type 2 diabetes inadequately controlled with insulin glargine plus oral agents found that albiglutide resulted in comparable HbA1c reduction with weight loss and lower hypoglycemia risk 3.
- Another study found that dulaglutide, a long-acting glucagon-like peptide-1 receptor agonist, resulted in greater HbA1c reductions compared to insulin glargine in patients with type 2 diabetes and different baseline glycaemic patterns 4.
Monitoring HbA1c Levels
- A study found that HbA1c increases by approximately 0.5% (5 mmol/mol) over 10 years after diagnosis of type 2 diabetes, with the main increase appearing in the first years after diagnosis 5.
- The study also found that more frequent monitoring of HbA1c and adjustments of glucose-lowering drugs may be essential to prevent the decline in glycaemic control.
Non-Glycaemic Variables Affecting HbA1c
- A review of non-glycaemic variables found that while some variables have statistically significant effects on HbA1c, the clinical implications are generally irrelevant, and HbA1c should continue to be used with confidence in most clinical scenarios 6.