This patient has a Hba1c of 8.0. He is obese and currently does not have any CV complications. The best treatment option for him would be to choose a medication that will address not only his high glucose but also his obesity and risk of complications.
The first choice for a second-line therapy by the new American Diabetes Association/European Association for the Study of Diabetes (ADA/EASD) guidelines is GLP1 RAs or SGLT-2 inhibitors for patients with atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease. For patients without these conditions, the ADA/EASD lists five options of noninsulin second-line therapy. On the other hand, the 2019 consensus statement from the American Association of Clinical Endocrinologists/American College of Endocrinology lists nine options, with GLP1 RAs as the first recommended therapy, followed by SGLT2 inhibitors and dipeptidyl peptidase 4 (DPP4) inhibitors, and sulfonylurea as the last option.
Currently Trulicity is the only GLP-1 agent that in addition to improving glucose and having the weight loss benefit will also provide primary prevention for CV disease.
Adding basal / bolus regime is currently not needed as many other options are available. Moreover, adding insulin will not provide the weight loss benefit and primary prevention CV benefit.
-Adding SGLT-2 inhibitor may be a good option however based on the above guidelines and primary prevention benefit associated with Trulicity once weekly GLP-1 seems like the best option. And it will also help him lose weight.
1-Trulicity [Prescribing Information]. Indianapolis, IN: Lilly USA, LLC.
2-Gerstein HC, Colhoun HM, Dagenais GR, et al. Dulaglutide and cardiovascular outcomes in type 2 diabetes (REWIND): a double‐blind, randomised placebo‐controlled trial. Lancet. 2019;394(10193):121‐130.
3-Gerstein HC, Colhoun HM, Dagenais GR, et al. Design and baseline characteristics of participants in the Researching cardiovascular Events with a Weekly Incretin in Diabetes (REWIND) trial on the cardiovascular effects of dulaglutide. Diabetes Obese Metab. 2018;20(1):42‐49.