Endocrinology
Uncontrolled Diabetes
Summary
- 74 y.o. male with uncontrolled diabetes
- Non-compliant patient with unusual medication regimen
- Specialist presents detailed treatment options for patient with and without resources
eConsult Transcript
PCP submission
This is a 74 y/o AA male that presents to the clinic to re-establish care. His recent A1c was 9.4. He was previously prescribed Janumet 50-100 BID, Novolin 70/30 (40 units in am and 30 units in the evening), and Toujeo (80 units in the am and 40 units in the evening). Patient admits he does not take his medications as prescribed. My plan is to continue Farxiga 10mg daily, Novolin 70/30 (40 units in am and 30 units in the evening), and make Toujeo once daily instead of BID.
PCP Question: Should the Toujeo be changed to once at night and keep the Novolin 70/30 BID?
Specialist response
Great question. He’s on a very unorthodox regimen. We typically don’t mix different basal insulins like NPH (the “70” in 70/30) and Toujeo. With his difficulty with adherence, I might offer the following: Stop the Januvia and offer metformin alone with the goal of eventually getting to the full 1000 mg BID dose if the GFR is >60 ml/min or 500 mg BID dose for a GFR of 30-59 ml/min. Sometimes using an XR formulation once daily is helpful for adherence. Stop the 70/30 and instead use Toujeo alone. I don’t trust his doses; I suspect they were raised in the past because people didn’t realize he wasn’t actually taking the shots. So, I’d just start at ~0.25 units/kg/night and plan to titrate it upward, aiming for most first-morning fingersticks <130 mg/dl. A simple ~1-3 units/day titration is generally safe. If you want to be more aggressive, we often use the old Treat-to-Target/Bergenstal titration, averaging first-morning fingersticks every 48-72 hours: BG <80—> reduce dose by ~2 units BG 81-109—> no change BG 110–139–> +2 units BG 140–179—> +4 units BG >180—> +6 units If he has CVD, proteinuria, or CKD, Farxiga is a great choice. If not, I’d offer something more potent for blood sugars. I like to split agents by cost. If the patient has limited resources, then a BID sulfonylurea like glimepiride 1 mg or glipizide 5 mg with the two largest meals of the day is a good choice. SFUs have some potential for hypoglycemia, so watch out for that. Pioglitazone is potent, CVD risk-neutral, or maybe even slightly protective (and cheap), but has some potential for fractures and weight gain that is problematic in many. And it’s contraindicated in almost anyone with CHF. Acarbose starting at 25 mg with each meal is safe, weight-neutral, and may reduce CVD risk. But its side effect of gas and bloating, along with the need to take it TID, makes it less attractive for some patients. If the patient has resources, though, I’d instead offer a long-acting GLP-1 agonist like dulaglutide, tirzepatide, or semaglutide, titrated to the highest tolerated dose as long as the patient has no history of pancreatitis and no family history of MEN2 or medullary thyroid cancer (routine, differentiated thyroid cancers or thyroid nodules are not a concern). Long-acting GLP-1s are particularly good for adherence.
And, in addition to continued annual complications screening, I’d offer the usual non-pharmacologic interventions: Diabetes education (DSMES) if the patient hasn’t had it (it reduces the A1c by ~0.3% and reduces all-cause mortality by ~26% or more). Q3 month teeth cleanings if possible, which are worth another ~0.5-0.6% A1c reduction. Gentle vitamin D supplementation may be worth another ~0.15% A1c reduction, particularly in older patients and patients of Asian descent. Supplemental fiber like Metamucil (psyllium husk) 1 tablespoon daily in water reduces the A1c level by ~0.6%, roughly equivalent to DPP-4 inhibitors like Januvia. It also reduces the LDL by ~15 mg/dl. If the fluid is a challenge, wafers or capsules are okay, too. And, for patients on insulin, switching to a continuous glucose monitor (CGM) is worth another ~0.5% A1c reduction. If, after 3-4 months of optimizing that regimen, his A1c is still unacceptably high, we’ll have to reconsider mealtime insulin at least with his largest meal of the day. I hope that’s helpful. If any of these suggestions seem impractical or infeasible in your clinic, I’d offer to send the patient to endocrinology. But I think this would be their general approach. Please reach out if any new questions or issues come up moving forward.
