Combining antidiabetes agents
Combination therapy is often needed as T2DM progresses, even though strict glucose control is generally not recommended for the elderly.31 The American Geriatrics Society advises avoiding additional medications other than metformin to achieve an A1C level below 7.5% in most older adults.
However, for older patients already taking metformin who are not at their A1C goal, consider adding a second agent, if not contraindicated. Potential agents include a GLP-1 RA, SGLT-2 inhibitor, DDP-4 inhibitor, or short-acting sulfonylurea (glipizide). Alternatively, basal insulin may be added. However, avoid combining a sulfonylurea with insulin, which greatly increases the risk of hypoglycemia.32 Consider adding a GLP-1 RA or basal insulin if the patient is not at his/her target A1C on oral therapy with multiple agents.3
Barbara Keber, MD, Glen Cove Hospital, 101 St. Andrews Lane, Glen Cove, NY; firstname.lastname@example.org.