Jardiance (empagliflozin) belongs to the SGLT-2 (sodium-glucose co-transporter 2) inhibitor class. SGLT-2 inhibitors block the reabsorption of glucose from the urine back into the blood. Other drugs in the SGLT-2 inhibitors group include:

1. Dapagliflozin &

2. Canagliflozin

Dulaglutide is a GLP (glucagon-like peptide 1) analog that inhibits GLP-1 receptors resulting in early satiety, delayed gastric emptying, increasing insulin secreting function, and decreasing glucagon secretion. Other GLP-1 analogs include:

1. Exenatide &

2. liraglutide

After a brief introduction of the drugs, Let's come to the case scenario ...

A 45 years of age obese female came to my clinic with uncontrolled blood glucose levels. She is diabetic for the past 12 years and currently on the following medicines:

1. Premixed insulin 70/30  - 16 to 22 units twice daily
2. Pioglitazone 30 mg once daily
3. Metformin 1000 mg twice daily

She is obese with a Body mass index of 34 kgs/m² and belongs to an upper social class. She is non-compliant to diet but does regular aerobic exercise. She is also fond of eating fruits including dry fruits. Her blood glucose ranges between 280 and 400 mg/dl. Her latest glycated hemoglobin was 10.5%. She has noticed body swelling and has gained weight over the past few months.

How should this patient be treated?

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Before writing my prescription, the following were some of the things I kept in my mind while prescribing her:

1. She is non-compliant to dietary advice.
2. She is obese
3. She has generalized body swelling
4. She has uncontrolled blood glucose and already on three medicines including insulin.
5. She is affording.

So, the first thing was the dietary counseling ...

- She was non-compliant to diet or - maybe she had an urge to eat more - maybe she had hypo and hyperglycemia resulting in the excessive urge to eat more

• The patient was asked to:
• • Avoid all unnatural bakery items.
  • Take fruits in small quantities
  • Reduce Carbohydrates in the diet (bread)
  • increase proteins in her diet.

2. Pioglitazone was discontinued since it can cause weight gain and edema. 3. Since her glycated hemoglobin was quite high, Insulin and metformin were continued in a fixed-dose. 4. She was started on Empagliflozin (Jardiance) in combination with metformin. Jardiance was started in a dose of 25 mg once a day. 5. Along with that, she was started on once-weekly dulaglutide 1.5 mg. The aim was to target her weight.

After two weeks of Jardiance (Empagliflozin) and dulaglutide ...

The patient's fasting blood glucose was 113 mg/dl and 2 hours postprandial blood glucose was 149 mg/dl. She lost 4 kgs of weight and her swelling improved remarkably. Her insulin dose was reduced by 2 units.

After another ten days, the patient started complaining of diarrhea, flatulence, and heartburn.

What should we do next?

Should we stop any of the medicines?

Should we add any medicines?