Dear Dr. Roach: I am a 64-year-old man, and my A1C level has been averaging around 7.4% for a number of years. I was diagnosed diabetic at age 54. My doctor has been trying several combinations of drugs over the last couple years to get my A1C below 7%.
I currently am maxed out on 25 mg of Jardiance, 2,000 mg of metformin ER and 14 mg of Rybelsus. However, I have many side effects related to urinary issues associated with Jardiance, and I am quite miserable.
My general question is: With these three drugs, is there any way to tell which one is helping the most versus the least? If Jardiance is only helping 25% and the other two are helping 75%, then I would discontinue Jardiance and figure out another way to lower my A1C. Or I would only take metformin and Rybelsus and see what happens with my next A1C.
R.
In any given person, it can be hard to predict which medicine will be the most effective, so the general rules I give might not correlate with how your body might respond or with what your doctor has found.
Metformin, which works by reducing the amount of sugar that the liver makes, is the usual first-line medicine used for people with diabetes, and it is expected to lower the A1C level by 1-2 percentage points. You are on the maximum dose.
Jardiance works by forcing your body to excrete glucose through the kidney, so bladder infections are possible. Increased urination is also very common. It is expected to lower the A1C level by about 0.5-0.7 percentage points; however, it has been shown to reduce heart disease risk in people with known blockages in their hearts and also protects the kidneys in people with diabetic kidney disease. It helps with weight loss as well.
Rybelsus also reduces heart disease risk and helps with weight loss. It can reduce the A1C by 0.5-2 percentage points, depending on the dose and whether it is given by mouth (Rybelsus) or injection (Ozempic).
Based on the averages in the overall population with diabetes, Jardiance is likely to have the least effect on your A1C out of the three medicines that you are taking. My guess would be that 85% of your benefit is coming from Rybelsus and metformin. However, Jardiance could be helping your heart and kidneys more than expected, based on the predicted A1C change.
When you talk to your doctor, be sure to explain that the urinary symptoms are really affecting your quality of life. I’m sure that your doctor wants the best outcome for you in managing your diabetes and reducing your risk of heart and kidney problems.
Although there are several other classes of medicines that you could try if you were to stop Jardiance, many people can reduce their overall need for medication by working on their diet and exercise. You can also benefit from taking a careful look at any other medicines you might be taking, some of which promote weight gain and higher sugar levels. A visit with a diabetes educator and a registered dietician might make a bigger beneficial difference in your A1C than what you could lose by not taking Jardiance.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth @med.cornell.edu
