3 Diabetes Case Challenges: Choose the Next Best Rx
These 3 case studies illustrate the challenges of intensifying treatment in complex T2D patients--and also the options available to individualize that next step.
There is significant flexibility now available when it comes to intensifying pharmacologic treatment for patients with type 2 diabetes (T2D). There is also a growing opportunity to individualize T2D treatment, both when changes to a regimen are needed and at initiation of medical therapy.The following 3 patient case studies illustrate a number of the common comorbidities and complications associated with T2D that make effective management like working on a jigsaw puzzle. With recent FDA label expansions for several classes of T2D drugs, however, it is getting easier to find a perfect fit.Based on your knowledge of the drugs and the science, what is the best next Rx for each of these patients - and why?
Case #1 patient history. A 72-year-old man with T2D and CKD with albuminuria (eGFR 40 mL/min 3 months ago) presents to clinic today. He is having hypoglycemia a few times a week. BG readings, mostly fasting and before dinner, range from 50-200 mg/dL. Metformin has caused him gastric upset in the past.
Which of the medication changes above would you discuss with him today as possibilities?
Answer: C. Stop glimepiride and start canagliflozin 100 mg/d. The sulfonylurea is probably part of the reason for the patient's hypoglycemia, so neither option A or B is appropriate.
Option C (stop glimepiride and start canagliflozin 100 mg/d) is the best answer, given the patient’s frequency of hypoglycemia and CKD. The CREDENCE (Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy) trial showed that in patients with T2D, CKD, & albuminuria, those randomized to canagliflozin had a significantly lower rate of the primary outcome (ESRD, doubling of creatinine, and renal- or CVD-related death) vs placebo.
Canagliflozin also has an FDA indication for risk reduction of ESRD, serum creatinine doubling, and cardiovascular death in patients with type 2 diabetes, nephropathy, and albuminuria.
Case #2 patient history. A 43-year-old woman with T2D, diagnosed at age 37, is in clinic; her A1c today is 8%; she has no micro- or macrovascular complications. She has severe obesity (BMI 42). She is on maximum dose metformin. She is trying to adhere to a healthy diet and also to walk 20 mins/day.
You talk with her about intensifying her antihyperglycemic regimen and she is in agreement, interested in an agent that will help her lose weight.
Which of the options above would you choose as a next step?
Answer: B. Oral semaglutide 3 mg/d for 4 weeks, 7 mg/d for 4 weeks, and then 14 mg/d. Glimepiride and other sulfonylureas are associated with weight gain. Sitagliptin and other DPP-4 inhibitors are weight neutral. In the phase 3a PIONEER 2 open-label trial, patients with T2D not controlled on metformin were randomized to either oral semaglutide or empagliflozin. At 52 wks, patients on semaglutide had significantly greater weight loss (P<.02) vs patients on empagliflozin; option B is best.
Case #3 patient history. A 52-year-old man with history of CAD status post CABG and ischemic cardiomyopathy is referred to your clinic by his cardiologist for management of T2D, diagnosed 5 years ago. He has no history of microvascular complications. He takes sitagliptin 100 mg/d & insulin degludec 15 U at night. His A1c today is 8.5%, renal function is normal. He was discharged last month after a hospitalization for volume overload secondary to a HF exacerbation.
Which agent above, if initiated, would benefit the patient in terms of reducing the likelihood of another hospitalization for HF?
Answer: Dapagliflozin 10 mg/d. Only dapagliflozin has an FDA indication to reduce risk of HF hospitalization in patients with T2D. The indication is based on data from the DECLARE-TIMI 58 trial, in which patients with T2D, less than half of whom had established CVD, were randomized to either placebo or dapagliflozin 10 mg/d.
