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William Ameen, Sai Kolla Commented on a Post
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Advancing oral treatment for Type 2 diabetes

Your obese type 2 diabetes patient, who is 58 years old, has been on metformin, but recent HbA1C levels are around 8.2%, despite attempts at controlling diet and exercise. The patient realizes something must be done and would very much like to maximize A1C reductions with the next option, hoping to achieve levels closer to a goal of 7.0%, if not below that, to avoid having to add multiple further medications. However, the patient hopes to avoid injectable medications if they are not completely necessary. The patient would also like to lose weight.

What medication would you recommend next?

Would your recommendation differ if the patient had a history of atherosclerotic cardiovascular disease?

How would you help this patient stay compliant with your prescribed treatment regimen?

  • 2 weeks 1 day
    Obviously, one must confirm that the patient is actually taking metformin, and if he can be believed, make sure he's on the maximum tolerable dose, 1000 mg of the extended-release with food. Firmly elaborate an exercise and diet plan; if possible, schedule an appointment with a dietician. In my mind after rechecking the Hgb A1C in 3 months and there is no improvement, adding a SGLT2i (particularly if he has ASCVD) will be beneficial as it assists in weight loss. If he has no way of affording a SGLT2i, consider adding psyllium fiber (a good example is the OTC brand Yerba Prima, 5 capsules twice a day) which modestly lowers cholesterol and gives a feeling of satiety.
  • 2 weeks 3 days
    Check his diet in detail, cut down Carbs 50% what he is taking and follow HbA1c. If not controlled, add januvia 50mg once daily
  • from Pharmacist Society 4 weeks
    I would check his insurance to see which SGLT2 inhibitor is preferred, then choose the version that includes metformin with it (i.e., likely either Xigduo XR or Synjardy XR), maximizing the dose of metformin and the SGLT2 inhibitor. Taking this combined product once daily will assist with compliance, but I would also show him how to use a medication organizer tray or smart phone app (like ‘Round’) to help him remember to take his medicine daily.

    These options will also work well in ASCVD, though a GLP1 analog may be of more benefit in this case. It would come down to how much the patient did not want to inject.
  • 4 weeks 1 day
    I would have him take maximum tolerable dose of Metformin. Would reduce GI issues with ER formulation and taking it with meals. Then I would use a GLP-1. Would try to use injectables and address his fears and any myths he may have about injections. If still refusing injectable, then would use oral Rybelsus which would help reduce weight and A1c. He would need to take it on an empty stomach first thing in the morning with a sip of plain water (no more than 4 ounces).
  • from Pharmacist Society 4 weeks 1 day
    I would keep with the oral therapy but change to the combo drug Janumet for reasons of compliance of only taking 1 tablet. Patients seems very motivated and may reach his A1C goal of <7.
  • from Generation NP 4 weeks 1 day
    I would try to adjust the dosage of the metformin if the patient is not on a max dose. I would also encourage proper weight, exercise and diet.
  • from Generation NP 4 weeks 1 day
    I would recommend max out the Metformin if she is already on that medication.
  • from Pharmacist Society 4 weeks 1 day
    Depends on his insurance and copays
    for those with no insurance or high copays i would recommend adding a low dose sulfonylurea such as amaryl 1-2mg daily, and walk !!! if you're committed to exercise you can walk off type 2

    If the patient has low co-pays on insurance , i would recommend whatever SGLT-2 that has the lowest copay on his plan be added, helps w/ BP and weight loss too.
    And walk !!!!!
  • from Pharmacist Society 1 month
    I would give the patient Jamumet to see how much the A1C will drop. This still gives the patient the option of taking one pill.
  • 1 month
    I need to know some further details about the pt, like their bmi, the dose of metformin they are on, do they have a glucometer and what sort of diet and exercise programs they are on. As far as meds go, I would max out the metformin at 2000-2500mg a day and just add one additional med at this time as each oral med will drop the hemoglobin A1C by about one point The next med I would add is alogliptin. John.
  • 1 month
    i would go with rybelsus based on the patients request for no injectable and the added weight loss benefit.
  • 1 month
    I would try ongylza.
  • 1 month
    I would start with Rybelsus that would help with better control of BS and also weight loss since patient prefers no injectables.
  • 1 month
    In this situation, the logical next step would be a stating 3 mg dose of semaglutide. The other choice reasonably be Jardiance 10mg. If the patient had clinical evidence of CVD, a GLP-1 agonist or an SGLT-2 inhibitor is logical. Adherence to the regimen can be enhanced by lower initial dosing and proper administration of semaglutide.
    Lee Besen
  • 1 month
    I would recommend semaglutide...it would help her lose weight and Sustain 6 showed a decreased risk of CV death, non fatal MI and non fatal stroke.
  • 1 month
    My recommendation would be a GLP-1 agonist such as semaglutide Rybelsus. This will reduce her A1C and help with weight loss. Taken orally, avoids injections which fulfills her requirement. Reduces risk to ACD. Follow up with patient to help with compliance.
  • 1 month
    I would recommend adding a 100mg dose of Januvia and a 2mg dose of Glimepiride to the Metformin
  • from Endocrinologist Nation 1 month
    I would recommend SGLT-2i or GLP-1 analog. Given his BMI, he will get the best results with weekly Ozempic or Trulicity. It will also be a better option if there is a h/o CVD. If pt has proteinuria then I’d try SGLT2i first!