Question: A 58-year-old female with a history of hypertension and hyperlipidemia presents with an A1c of 9.1% and fasting blood glucose of 142 mg/dL. Her recent lipid panel shows LDL cholesterol at 160 mg/dL. What is the initial approach to managing her glycemic control, and which medications would you consider starting?

Answer: Given the patient's A1c of 9.1% and fasting blood glucose of 142 mg/dL, along with her history of hypertension and hyperlipidemia, it is important to initiate a structured approach to glycemic control. The American Diabetes Association (ADA) recommends targeting an A1c below 7.0% for most adults with type 2 diabetes. For this patient, starting a combination therapy that addresses both glucose control and cardiovascular risk factors is advisable. Metformin 500 mg twice daily can be initiated, which is effective in lowering A1c and has been shown to improve cardiovascular outcomes. If metformin alone does not achieve adequate glycemic control, adding a glucagon-like peptide-1 (GLP-1) agonist such as liraglutide 0.6 mg once daily or exenatide 2 mg twice weekly could be considered. These agents have demonstrated benefits in reducing A1c while also improving cardiovascular risk factors. Additionally, a SGLT2 inhibitor like empagliflozin 10 mg once daily could be added, as it provides additional cardiovascular benefits and helps lower A1c and blood pressure. Monitoring A1c every 3 months and adjusting medications based on response is recommended. It is crucial to monitor for potential side effects such as gastrointestinal issues with GLP-1 agonists and increased risk of genital infections with SGLT2 inhibitors. Regular blood pressure and lipid profile monitoring are also necessary. Safety disclaimer: Close monitoring and dose adjustments are required to minimize risks associated with these therapies.