Skill Checkup: A 55-Year-Old Man With Type 2 Diabetes and High A1C Level Despite Previous Treatments

Romesh Khardori, MD, PhD


April 27, 2023

Patients presenting with HbA1C of 1.5%-2.0% above target HbA1C can benefit from initial combination therapy with metformin plus another agent to achieve glycemic control in a timely manner. This approach is recommended by the ADA.

Combinations of metformin with SGLT2 inhibitors or DPP-4 inhibitors provide additional benefits in HbA1C reduction by addressing different aspects of T2D pathophysiology. This patient likely would have benefitted from more intensive therapy at the start to bring his HbA1C down to target and prevent complications related to unnecessary exposure to hyperglycemia.

As an added plus for this patient, fixed-dosed formulations of metformin with an SGLT2 or DPP-4 inhibitor help to limit patients' pill counts. He has complained that the complexity of his current regimen contributes to missed doses of some of his medications, a common finding in studies of medication adherence. A combined option might help him better adhere to therapy.

Another frequent issue is so-called therapeutic inertia, in which patients remain on their original treatment despite not achieving treatment goals. The ADA considers this problematic enough to have launched a 3-year initiative to address the issue of declining rates of patients achieving HbA1C targets (< 2 in 3) and increasing rates of patients living with HbA1C > 9% (15.5%).


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