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When Changing to Combo Pill, Know the Dosages You are Changing

Mar 14, 2017

Woman, 62 years of age, musician, travels often, type 2 diabetes, obesity, hyperlipidemia, fatty liver. Was traveling for two months straight on the road. Late nights/parties and a lot of drinking. Admitted not having taken her GLP-1 or really following any meal or healthy life plan/schedule she was following before leaving. Since last office visit 3 months ago, weight up 10 pounds, fasting glucose 170 in office. She was on her way to her pcp for more labs.

Patient reported seeing her pcp two weeks ago who d/c’d her metformin, which she had been taking 1,000mg twice daily, and she was started on Xigduo once daily. Did not know the dosage and she had not taken Victoza for over 2 weeks. She had been taking 1.8mg daily. Does not perform self glucose monitoring.

Recommended patient resume Victoza at 0.6mg and increase every 3 to 4 days as tolerated by 0.6mg until back up to the 1.8mg daily. Asked patient to let me know the dosage of the Xigduo. Resume low carb meal plan, and perform self glucose monitoring at least twice daily, fasting and bedtime. Did provide education about Xigduo and what this is a combination drug of and how it works.

Labs received:

A1C increased from 6.2% to 7.9%, fasting glucose 168, lipids which were within target range 3 months ago, now total cholesterol 296, HDL down-28, Triglycerides 672-LDL unable to calculate due to triglycerides being over 400. AST from 70 to 244,  ALT 150 to 32.  Patient called me stating she feels awful. Could it be due to anything in her labs?

We talked. I told her it very well could be due to what we saw in the labs, how the lifestyle had affected her health and the seriousness of “going off track” to that extent. She then also told me the Xigduo was 10/1000, but she really never started that due to insurance issues until the day before we talked. That means she was without the metformin altogether for at least a few weeks. She had resumed the Victoza and was back to the 1.8mg dosage.

She had not started self glucose monitoring. Admitted to her meter not working. I prescribed a new meter and strips for her. Informed her that the metformin dose she was taking was more than what is in her Xigduo. Recommended she discuss this with her pcp who may want to add 1,000mg, so she is back to the metformin dose she was on that did help her.

The last I spoke with patient, she said she’ll give it a week, and discuss adding the 1,000 mg of metformin if her glucose levels don’t come back to her target range.

In honesty, I can’t help but think this woman, who was diagnosed with type 2 diabetes only 6 months ago, may have been in denial about the diagnosis. I think this episode made a believer out of her. Time will tell.

Lessons Learned:

  • Diabetes management is not easy. There are a lot of lifestyle/medications to follow and take. When schedule is off, diabetes management will most likely be affected in a negative way.
  • People who are newly diagnosed with diabetes don’t always realize the ramifications of getting off track. For some, seeing what getting off track can do may be the wake up call to stick with the program or at least some aspect of it.
  • When changing patients to a combo oral med, teach the components of the medication-effects and side effects to be aware of. If there is a replacement of a medication the patient is already taking, be aware of and teach the difference in the dosage.
  • Know and teach that it may not be as easy to get a combo pill approved as it is to get the separate medications paid for. If not covered, don’t stop all treatment-let prescriber know so there does not have to be a discontinuation of therapy.
  • When patients get off track-don’t judge. Life doesn’t just change because someone has diabetes. Work with your patients to help make diabetes better fit their lifestyle. True lifestyle may need to change, but change doesn’t usually happen overnight.


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