My sugars are high despite medicines. Should I add Insulin?

Question

Hello doctor,

I am 48 and was diagnosed with type 2 diabetes five years ago. My recent HbA1c came to 8.2 despite taking Metformin 1000 milligrams twice daily and Glimepiride 2 milligrams. My fasting sugar stays around 168, and post-meal goes above 250 often.

So my questions are -

Should I ask my endocrinologist about adding Insulin now, or try SGLT2 inhibitors like Dapagliflozin first?
My creatinine is 1.3, so are these newer medicines safe for the kidneys?
Can uncontrolled sugar for a long time lead to nerve or eye problems?
How often should I do retinopathy and neuropathy screening?

I am trying to figure out the best next steps before the condition worsens.

Kindly help.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

Your glycated hemoglobin (HbA1c) of 8.2 percent shows that your diabetes is not well controlled despite taking Metformin and Glimepiride.

At this stage, doctors usually consider either adding a medicine from the sodium-glucose co-transporter-2 (SGLT2) inhibitor group (such as Dapagliflozin or Empagliflozin) or starting Insulin therapy if blood sugar levels remain persistently high.

SGLT2 inhibitors are often a good next step because they not only lower blood sugar but also protect the heart and kidneys. They are generally safe provided your kidney function is adequate (estimated glomerular filtration rate (eGFR) above 45 milliliters per minute and serum creatinine within normal limits).

However, if your blood sugar remains uncontrolled, Insulin may still be needed, sometimes even for a temporary period. Uncontrolled diabetes over time can damage the nerves (diabetic neuropathy), eyes (diabetic retinopathy), and kidneys (diabetic nephropathy), and significantly increase the risk of heart disease.

That is why regular monitoring is essential, which includes:

Annual eye examination.
Annual neuropathy and foot check.
Kidney function tests and urine protein test every six to 12 months.
Regular blood pressure and cholesterol monitoring.

In short, it would be wise to discuss with your endocrinologist about starting an SGLT2 inhibitor as the next step, while keeping in mind that Insulin therapy may be added later if needed. Alongside medicines, following a low-carbohydrate diet, regular exercise, and weight management will significantly improve your long-term health outcomes.

I hope this information helps you.

Thank you.