My HbA1c is high despite Metformin. Should I add GLP-1?

Question

Hi, doctor,

I am 54 and have had type 2 diabetes for eight years. My recent HbA1c came back as 8.4 %, and fasting sugar levels are often above 160 even though I take Metformin 1000 mg twice daily. I also walk 30 minutes daily and follow a low-carbohydrate diet.

My cholesterol and blood pressure levels are fine, but I have been feeling increasingly tired lately. So I am looking for your suggestions on the following:

Should I consider adding another medication, like a GLP-1 or SGLT2 inhibitor?
Are there risks associated with combining these with metformin?
Also, how often should I get my kidneys and eyes checked if my sugars remain this high for a while?

Kindly suggest.

Answer 1

Hi,

Welcome to icliniq.com.

I understand your concern.

Based on your current situation, being 54 years old with type 2 diabetes for eight years and an HbA1c (glycated hemoglobin) of 8.4% despite taking 1000 mg of metformin twice daily, walking daily, and following a low-carbohydrate diet, it is time to consider adding another medication to improve your blood sugar control.

Here is the answer to your questions:

Both GLP-1 receptor agonists (such as Semaglutide or Liraglutide) and SGLT2 (sodium-glucose cotransporter 2) inhibitors (such as Empagliflozin or Dapagliflozin) are safe and effective options to use alongside Metformin.
GLP-1 agonists typically offer stronger HbA1c reduction and promote weight loss, while SGLT2 inhibitors also help with modest weight loss and have added benefits for heart and kidney protection.
The choice between them may depend on your specific needs, such as weight loss goals, cardiovascular or kidney health, and preference for injectable versus oral medication.
There are no significant drug interactions between Metformin and either class of medications. However, GLP-1 (glucagon-like peptide-1) agonists can sometimes cause nausea or gastrointestinal discomfort, while SGLT2 inhibitors sometimes increase the risk of urinary or genital infections and mild dehydration.

Given that your blood sugar remains high, it is important to monitor for diabetes-related complications. So get the following tests done regularly:

You should have your kidney function (eGFR (estimated glomerular filtration rate) and urine albumin to creatinine ratio) checked at least once a year, or more often if abnormalities are detected.
A dilated eye exam should also be done annually to screen for diabetic retinopathy.
In addition, a yearly foot exam by a healthcare provider and daily self-checks at home are essential to prevent complications.

The increased fatigue you are experiencing is related to prolonged high blood sugar levels but may also suggest other underlying issues, such as the following:

Anemia.
Thyroid dysfunction.
Vitamin B12 deficiency (which can be caused by long-term Metformin use).
Sleep apnea.

Tests like complete blood count (CBC), thyroid function tests, B12 levels, and iron studies are also needed.

I hope this helps.