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How should I adjust the medication regimen for a patient with type 2 diabetes who is not achieving glycaemic control on metformin alone?
Answer
When a patient with type 2 diabetes is not achieving glycaemic control on metformin alone, the initial steps involve reinforcing lifestyle measures, assessing adherence to treatment, and arranging timely follow-up 1,2. Treatment targets should be individualised based on the person's preferences, risk of adverse effects, frailty, and co-morbid conditions 1,2.
If HbA1c levels are not adequately controlled by metformin monotherapy and rise to 58 mmol/mol (7.5%) or higher, reinforce advice about diet, lifestyle, and adherence to drug treatment 3. Support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and intensify drug treatment 3. For adults whose type 2 diabetes is managed by lifestyle and diet combined with a single drug not associated with hypoglycaemia (like metformin), the aim is typically an HbA1c level of 48 mmol/mol (6.5%) 3.
When considering additional medication, assess the person's cardiovascular status and risk to determine if they have chronic heart failure, established atherosclerotic cardiovascular disease (ASCVD), or are at high risk of developing cardiovascular disease 1,2,3.
- If the patient has chronic heart failure or established ASCVD, offer an SGLT-2 inhibitor with proven cardiovascular benefit in addition to metformin 1,2,3.
- If the patient is at high risk of developing cardiovascular disease, consider an SGLT-2 inhibitor with proven cardiovascular benefit in addition to metformin 1,2,3.
For other adults with type 2 diabetes who do not fall into the above cardiovascular risk categories, consider adding one of the following to metformin:
- A dipeptidyl peptidase-4 (DPP-4) inhibitor 1,2.
- Pioglitazone 1,2.
- A sulfonylurea 1,2.
- An SGLT-2 inhibitor, which may be considered if a sulfonylurea is contraindicated or not tolerated, or if the person is at significant risk of hypoglycaemia or its consequences 1,2.
The choice of drug treatment should be based on the person's individual clinical circumstances (e.g., comorbidities, contraindications, weight, polypharmacy risks), preferences, effectiveness in terms of metabolic response and cardiovascular/renal protection, safety, tolerability, monitoring requirements, licensed indications, combinations, and cost 1,2,3.
If an adult with type 2 diabetes is symptomatically hyperglycaemic, consider immediate insulin therapy or a sulfonylurea, and review treatment once blood glucose control has been achieved 1,2,3. Self-monitoring of capillary blood glucose levels is not routinely offered unless the person is on insulin, has evidence of hypoglycaemic episodes, is on oral medication that may increase hypoglycaemia risk while driving, or is pregnant/planning pregnancy 3. Short-term self-monitoring may be considered when starting oral or intravenous corticosteroids or to confirm suspected hypoglycaemia 3.
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