Clinical Situations 

M.M., a 63-year-old woman, has had Type 2 diabetes for 10 years. She is currently taking Metformin 500 mg PO TID & insulin glargine 47 units at bedtime. Her A1C is 8.2%. She tries to follow a meal plan that a dietitian developed for her but her BMI remains 31 kg/m2. Her physical activity is limited because of an arthritic knee, for which she plans to have knee replacement surgery in the future. Other medical problems include HTN, and dyslipidemia, which are both well controlled. Her medications are HCTZ 25 mg PO Daily, benazepril 40 mg PO Daily, and atorvastatin 40 mg PO Daily. M.M’s niece, who accompanied her for today’s office visit, subtly hinted that she has recently begun trying to monitor M.M’s memory.

Assignments

1. Can any antidiabetic agent/s be added to M.M’s current therapy?
2. Please list complete regimen (name, dose, route, frequency) of any added agent/s
3. Please state rationale for choice of any agent/s added

 

Before I change any regime, I need to make sure that patient is adherent to the current regime because adding other agents can cause hypoglycemia and further issues. I need to make sure the patient adherent to meal plan and take the indicated medication in right dose and in right time of the day.

According to the guidelines, initial treatment for diabetic patients are lifestyle modification, and metformin. If the initial treatment fails, then a second agents can be added before starting insulin to control the hemoglobin A1C. The correct regime for this patient should be a long acting insulin at bedtime and bolus at every mealtime since the her A1C is 8.2%.  However, the patient is experiencing memory issue and have a pretty extensive medication list, so adding a bolus would be too demanding for this patient. Therefore, to compensate for the patient’s need, I would like to prescribe a second agents such as GLP-1 receptor agonist, which can help the patient to lose weight and lower the A1C level. GLP-1 receptor agonist, Liraglutide, can be given as injection and can be administered only once a day, which can help the patient to adhere to the new regime. Furthermore, a 26 weeks trials illustrate Liraglutide can reduce A1C more effectively compared to glargine. In order to reduce the gastrointestinal side effects, initial dose of Liraglutide should be 0.6mg once daily for one week, and then the dose could be increased to 1.2 mg once daily.

 

Complete Regimen

1. Metformin 500 mg PO TID
2. Liraglutide 0.6 mg SQ once daily for 1 week then 1.2 mg SQ once daily
3. Insulin glargine 47 units at bedtime
4. HCTZ 25 mg PO Daily
5. Benazepril 40 mg PO Daily
6. Atorvastatin 40 mg PO Daily

 

Sources:

1. https://www.victoza.com/
2. https://www-uptodate-com.york.ezproxy.cuny.edu/contents/glucagon-like-peptide-1-receptor-agonists-for-the-treatment-of-type-2-diabetes-mellitus?search=Liraglutide%20dose&source=search_result&selectedTitle=2~37&usage_type=default&display_rank=1#H1201977
3. https://www.uptodate.com/contents/liraglutide-drug-information?search=diabetes%20mellitus%20type%202%20management&topicRef=1790&source=see_link
4. Russell-Jones D, Vaag A, Schmitz O, et al. Liraglutide vs insulin glargine and placebo in combination with metformin and sulfonylurea therapy in type 2 diabetes mellitus (LEAD-5 met+SU): a randomised controlled trial. Diabetologia 2009; 52:2046.
5. https://www-uptodate-com.york.ezproxy.cuny.edu/contents/management-of-persistent-hyperglycemia-in-type-2-diabetes-mellitus?search=type%202%20diabetes%20treatment&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H7554285