I would stop the sulfonyurea and start a GLP-1 to help with weight loss !

I would make sure she is on the max dose of Metformin 1000mg BID, stop the sulfonyurea and add with GLP-1 such as Ozempic (greater weight loss) and possibly adding SGLT2. I would also incorporate Lifestyle changes exercise 150 mins per day, look at serving sizes, decrease processed foods).

I would add either GLP-1 agent like Rybelsus 1st before SGLT-2 agent as greater weight loss with GLP-1s

i would discontinue sulfonylurea, evaluate any life style changes like diet and exercise and add GLP-1 like trulicity. If injections were a compliance issue for patient, i would consider rybelsus. GLP-1’s usually make for a 1 to 2 point drop in A1c. This would be my next step in a perfect world where insurance/cost to patient would be a nonissue.

Change DDP-IV to Ozempic or Trulicity or Rybelsus if oral is preferred

I agree with my colleagues, this pt will certainly benefit from starting an oral or injectable GLP-1 agonist, rybelsus Trulicity or Ozempic, she will have to stop her DPP-4i. Other option is adding jardiance or invokana to her regimen

She should stop her DPP-IV and start a once a week injectable GLP-1 agonist for better A1c reduction with benefits of weight loss and cardiovascular health and may result in removing the need for the sulfonyurea. If she is afraid of injectables, start Rybelsus instead. Also set her up with an appointment with a Nutritionist.
Recheck A1C in 2-3 months.

Would inform her to stop her DPP-IV and start a once a week injectable GLP-1 agonist that would achieve better A1c reduction with benefits of weight loss and improved blood pressure and may result in removing the need for the sulfonyurea medicine. Would also inform her, there continues to be development in the diabetes medicine and soon there will be a dual GLP / GIP medication (Tirzepatide) which will further improve diabetic control as well as more weight loss and BP control. Would also stress importance of lifestyle changes to include diet and exercise for more long term gains.

I would stop DPP 4 inhibitors and sul. Add SGLT2 and GLP1. I would consider Farxiga and Rybelsis

If pt is averse to needles, try Jardiance or similar in class; otherwise Levemir and titrate

stop the sulfonyurea and start a GLP-1 to help with weight loss and to improve the A1C. Also recommend Diabetes Education.

If the pt is truly compliant with the regimen, I recommend stopping the sulfonurea and DppIV. I would then add an SGLT2 and GLP1. I would also review the lifestyle and diet for modifications.

I think there are many things to consider prior to changing therapy in this patient.

1. I would assess if the patient is truly tolerating the current regimen. Especially with metformin, I have found that some patients end up missing doses due to significant GI side effects.
2. The patient is now on 3 drugs alone to manage their DMII. I would assess how they are taking these medications and their understanding as to what they are for as some patients struggle with health literacy and may encounter difficulties in managing complex medication regimens.
3. I would delve into if the patient is having difficulty accessing their medications, either from a financial barrier standpoint, or if they are having transportation issues etc that preclude their ability to obtain their medications.
4. I would go over their blood sugar log to see we can find patterns for when their blood sugar is spiking and find possible triggers to intervene on.
5. If the patient has not seen a nutritionist yet, I would get them set up with a nutritionist in order to help them learn about a DMII diet and how to count carbs, read nutrition labels, which can be overwhelming for someone with a new diagnosis with DMII.
6. We would also discuss non-pharm interventions such as exercise as well.

I would assess all of this prior to stepping up their medication regimen or switching therapeutics.

I would discontinue sulfonyurea start once weekly GLP1 for now decrease the dose of DDP4 and if doesn’t get the target hba1c will switch DDP 4 to SGLT2.

I would stop the sulfonurea and DppIV…add an SGLT2 and GLP1…better efficacy safety and cardio renal protection

I would dc sulf and dpp4. Start GLP1ra like Ozempic or Rybelsus. Add sglt2i next if necessary

A semaglutide will help with diabetes and weight.

I would eliminate the DPP4 inhibitor and start weekly GLP1 RA such as Ozempic. At the same time would reduce the SU dose to avoid hypoglycemia. Hopefully pt will lose weight and BG a will drop. Depending on response would try eliminating SU completely while titrating up the Ozempic to maximally tolerated dose.

I would stop the sulfonyurea and start a GLP-1 to help with weight loss and to improve the A1C. Also recommend Diabetes Education.

I would recommend replacing DPP 4 I with GLPI1 or SGLT2 I for better A1C drop, weight loss and CVD benefits

Stop Metformin, add janumet 100/1000, alson Glipizide 10mg to start

BMI down to 25 -26 and hemoglobin A1 C to be below 7 - goal can be discussed

I would consider to stop sulfonylurea - as it can cause weight gain ! Healthy diet - exercise regimen should be prescribed

I will consider to add GLP-1 or SGLT2 inhibitor if covered by patient’s insurance

Behavior modification and life style changes is the first step. Nutrition consult , healthy eating exercise or walking , 30 minutes at least 3 times a week is advised and then discuss modification of medication regimen with patient

The safest and least costly way to go would be to have patient lose weight with help of a diet coach/nutritionist ; along with regular exercise; if this is not possible, then stop sulfonylurea, as it causes weight gain; dpp4 drug is not very potent so would stop it and use glp1 agonist, as it is fairly potent and can induce some weight loss. Insulin often also leads to weight gain.

This time and age there is no place for Sulphonylureas excpet for extreme economical circumstances that does not seem to be the case here as pt is on DDP-IV inhibitor ! In any case Sulphonnylurea needs to be stopped , Metformin needs to be continued , While diet and exercise needs to be reviewed and need to be opitmized in every possible way , The choices of add on are now between a GLP-1 or SGLT-2 , GLP-1 will be more desirable given the BMI of 30 and Oral Rybelsus or any of the daily or weekly injectable option can be chosen based on pt's preference , If GLP-1 is chosen then DDP-IV needs to be stopped as it is GLP-1 is a muich superior Inrectin Mimmetic drug , SGLT2- Inhibitor can also be considered if there is any contraindaction to GLP-1 or can be added later on the regimen after being on Metformin and GLP-1 !

I would add GLP1 or SGLT 2 inhibior, should help with diabetes as well as with weight loss

Her A1C needs to be below 7 where complications start to come in. I would try some low dose insulin

I would focus more on diet and exercise as I believe if we got her BMI down to 25 for hemoglobin A-1 C would be at goal. I would also have her see a nutritionist.

I would assess her lifestyle management, diet and exercise, would also start on GLP1, stop the dpp4, send to a nutritionist

In accordance with the MACE data, I would try to get her onto an GLP-1 and/or SGLT-2. This may be a financial burden but can improve her lipid profile, weight loss, and reach the goal of 7 they are setting.

Given that her PMD started the patient's treatment with metformin and a sulfonylurea, I suspect that the medication choices were limited by the patient's financial situation and insurance coverage. That being said, I would start off with having a frank and upfront discussion with the patient as to her ability to absorb the financial impact of medication changes and/or medication additions. I would also discuss if she is willing to use injection medications before considering glp-1 receptor agonists. I would also point out to the patient that a glp-1 ra medication would help her the most with weight loss and dyslipidemia as that might influence her decision. In a perfect world with no financial/insurance limitations, and no liver/renal function concerns, then I would vote for triple therapy with metformin, a glp-1 ra and a sglt 2 inhibitor in combination with diet/exercise and a diabetic diet. John

Perhaps add Actos or Jardiance; if PPG are high, consider Precose

Stop sulf and dpp4
Add sglt 2 and glp1
Better efficacy, weight loss and MACE data

stop the sulf and DPP4 add glp-1 and sglt2

I would add a GLP1 to help with weight but also to help preserve beta cell function, which the sulfonyurea and DPP-1V inhibitor don't address. If she loses weight, may no longer need as much medicine, especially if she is preserving her beta cell function.

I would find out whether GLP-1 or SGLT2 inhibitor is covered on insurance and prescribe any one of those. I would hold the sulfonyurea until I saw how new med was going, and then hope to d/c it.
As always we would make lifestyle modification goals such as 5% weight loss.

I would add a GLP-1

In addition to possible medication changes, I would assess her diet and activity level. I would advise her to increase vegetables and decrease all animal protein to 12-15oz per week, along with walking 30 minutes 3 times a week. I would test her urine for microalbinurea. All these interventions are in cadence with the National Kidney Foundation recommendations.

I would consider dual therapy with metformin and a long acting GLP1-RA such as Trulicity. if that was insufficient then I would consider adding Jardiance