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Clinician’s Corner: Type-2 Diabetes COMBINATION THERAPY

We are all familiar with Metformin (Glucophage) knowing it is the first drug prescribed for our Type-2 Diabetic (T2DM) patients.  As we are all aware, rarely is this monotherapy effective unless our patient makes the necessary lifestyle modifications.  Most references show that only 7% of T2DM patients will make the necessary lifestyle/dietary modifications necessary to combat this disease that is now affecting 1 out of 10 Americans.  For the other 93% of our patients we need to look at additional pharmacotherapy to manage their Type-2 Diabetes.

COMBINATION THERAPY

Even with drug treatment Type-2 diabetics, will eventually need additional therapy to treat their hyperglycemia.

  • After 3 years, 50% of patients will need a second drug
  • After 9 years, nearly 75% will need the second drug added.
  • Most common combination therapy if cost is a concern is sulfonylurea + metformin.
  • As diabetes progresses a third drug is often added—either another oral agent, GLP-1, or insulin.
  • Addition of insulin should NOT be postponed in patients with poor glycemic control that have failed on multiple drug regimens.
  • Look at the patient, consider need for weight loss, adherence, insurance coverage, cost of medications etc.

PUTTING IT ALL TOGETHER FOR COMBINATION THERAPY

Treatment Expected decrease in HbA1c Estimated monthly cost
Exercise, diet weight loss 1-2%  
Metformin 1.5% $8.00
Avandia/Actos 1-1.5% $12.00
Sulfonylurea (glipizide, glimepiride, eglyburide) 1.5% $8.00
Alpha glucosidase inhibitors (Precose/Glyset) 0.5-0.8% $22.00
Glinides (Starlix/Prandin) 0.5-1% $30.00
Incretins (Victoza, Trulicity, Ozempic) 1-1.5% $800.00
DPP4 inhibitors (Januvia, Tradjenta) 0.5-1% $500.00
SGLT2 inhibitors ((Invokana, Jardiance, etc) 0.5-1% $550.00
insulin -basal 1 vial 1.5-3.5% $320.00

*Consider initial therapy with insulin if HbA1c is greater than 10%, fasting glucose is over

Example:  the goal A1C you set is 7% for example.

If a patient comes in with a HbA1c =9 there is NO way he can get there by adding Januvia®!

Your Thompson Pharmacist can help you and your physician decide what treatment options are best for you.  Go Ahead and Ask, at Thompson Pharmacy It’s All for YOU!