From the Guidelines
For this 71-year-old Hispanic male with CKD stage IIIa who has experienced a significant A1c increase from 6.8% to 8.0% while on Farxiga (dapagliflozin) 10 mg daily, 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 titration to 1 mg weekly if needed and tolerated. This recommendation is based on the most recent and highest quality study available, which suggests that GLP-1 receptor agonists are effective in improving glycemic control and offer cardiovascular benefits, particularly in patients with CKD 1. The combination of a GLP-1 receptor agonist with an SGLT2 inhibitor like Farxiga is a reasonable approach, as these medications have complementary mechanisms of action.
Some key points to consider when initiating semaglutide include:
- Monitoring for gastrointestinal side effects such as nausea and vomiting, which typically improve over time
- Regular kidney function monitoring, though GLP-1 agonists generally don't require dose adjustment for his level of kidney impairment
- Potential benefits of semaglutide include improved glycemic control, cardiovascular benefits, and potential weight loss
- If GLP-1 therapy is contraindicated or not tolerated, a DPP-4 inhibitor like linagliptin would be an alternative second-line option that doesn't require renal dose adjustment, as supported by studies such as 1 and 1.
It's also important to note that the patient's kidney function should be closely monitored, as the glucose-lowering efficacy of SGLT2 inhibitors like Farxiga may be reduced at lower eGFR levels, but the cardiovascular and kidney benefits are preserved 1. Overall, the addition of semaglutide to the patient's current regimen is a reasonable and evidence-based approach to achieve better glycemic control and reduce the risk of cardiovascular complications.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment Options for Type 2 Diabetes
The patient is a 71-year-old Hispanic male with CKD stage IIIa, presenting with a spike in A1c from 6.8% to 8.0%, and is currently only on farxiga 10 mg daily. Considering the treatment options, the following points are relevant:
- The patient is already on an SGLT2 inhibitor (farxiga), which has been shown to be effective in reducing HbA1c, body weight, and blood pressure 2.
- Adding a DPP-4 inhibitor to the patient's treatment regimen may not provide significant additional benefits in terms of HbA1c reduction, as seen in studies comparing DPP-4 inhibitors to SGLT2 inhibitors 3, 2.
- However, DPP-4 inhibitors have been shown to be effective in reducing HbA1c when used as monotherapy or in combination with metformin 4, 5.
Considerations for CKD Stage IIIa
For patients with CKD stage IIIa, the following considerations are important:
- SGLT2 inhibitors, such as farxiga, have been shown to be effective in reducing the risk of kidney disease progression and cardiovascular events in patients with CKD 2, 6.
- DPP-4 inhibitors may also be effective in patients with CKD, but their use should be carefully considered due to the potential risk of hypoglycemia and other adverse events 4, 5.
Potential Treatment Additions
Based on the available evidence, potential treatment additions for this patient could include:
- Continuing the current dose of farxiga and monitoring the patient's response, as the medication has been shown to be effective in reducing HbA1c and improving cardiovascular outcomes 2, 6.
- Adding a DPP-4 inhibitor to the patient's treatment regimen, but carefully considering the potential risks and benefits, particularly in the context of CKD stage IIIa 4, 5.
- Considering other treatment options, such as GLP-1 agonists or pioglitazone, which may be effective in reducing HbA1c and improving cardiovascular outcomes, but may also have potential risks and benefits that need to be carefully considered 4, 5.