Management of the T2D Patient With High A1C.

It is widely known that the extent of time spent in a state of hyperglycemia increases the risk of complications for patients with type 2 diabetes (T2D). However, despite the availability of many antihyperglycemic agents, success in managing T2D has not dramatically improved in recent years. Indeed, therapeutic inertia-the failure to initiate or intensify treatment-is a well-characterized phenomenon. In this roundtable, the speakers discuss the management of individuals with A1C ≥9% despite treatment with 2 or 3 oral antihyperglycemic agents, who represent a large patient population requiring treatment intensification. The speakers first discuss the severity of complications emanating from lack of glycemic control, and the effect of beta-cell loss on glycemic control. They recount findings that approximately 50% of beta-cell function has been lost at diagnosis, and discuss the impact of beta-cell loss on treatment considerations. Next, the speakers discuss treatment options, in particular, glucagon-like peptide-1 receptor agonists -1(GLP-1 RAs). -1(GLP-1 RAs) can preserve beta-cell function, in patients with T2D duration of up to 10 years, but have been shown to exhibit reduced efficacy in patients with longer T2D duration. They go on to discuss iGlarLixi and iDegLira (fixed-ratio combinations of insulin glargine/ lixisenatide and insulin degludec/liraglutide, respectively), which have been shown to be effective in patients with A1C ≥9%. The speakers discuss the positive outcomes associated with a shorter interval between diagnosis and intensive insulin treatment, and the benefits of timely treatment intensification. They also provide practical advice for counseling patients to achieve an effective transition to injectable medication.