A 47-year old patient returns for a follow-up visit. He currently takes metformin 2000 mg daily, but is not achieving his glycemic target of A1C <7%. His current A1C is 8.0%. You would like to add a second medication to his regimen, however he voices concern that he is no longer covered by any health insurance and is worried about how to pay for his medications. Taking his concern into consideration, what drug would you add to metformin?
A 2-drug combination is the appropriate next management step for this patient. When the cost of medications is a concern, metformin + sulfonylurea is the lowest cost combination. Relative costs of antihyperglycemic medications are as follows. Low Cost: metformin, sulfonylureas. Moderate Cost: a-glucosidase inhibitors. High Cost: meglitinides, thiazolidinediones, DPP-4 inhibitors, bile acid sequestrants, dopamine-2 agonists, GLP-1 agonist, amylin mimetics. Variable: insulins. Remember that most likely the patient may go to insulins with the next addition and is usually the most effective drug for controlling blood sugars and the older insulins like NPH and Regular are very reasonable and are 10 times less expensive than the new insulins. Plus all insulin and even drug companies have programs for those that cannot afford the newer medicines.
Inzucchi S, et al. Management of hyperglycemia in type 2 diabetes: A patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012; 35(6):1364-1379.