Liraglutide, a glucagon-like peptide-1 (GLP-1) receptor agonist, is an appropriate adjunctive agent with metformin in this patient as it will improve glycemic control and contribute to desired weight loss. There are potential concerns for development of pancreatitis and medullary thyroid carcinoma with GLP-1 receptor agonists. The patient does not have a personal or family history of these abnormalities to preclude use of liraglutide.
Empagliflozin, a sodium-glucose transporter-2 (SGLT2) inhibitor, may be added to metformin when the hemoglobin A1c remains above goal. SGLT2 inhibitor use improves glycemic control and induces weight loss, but it also increases the risk of genital mycotic infections. Empagliflozin should not be used in this patient because it may exacerbate her frequent vulvovaginal candidiasis infections.
Glipizide, a sulfonylurea, may also be added to metformin when the hemoglobin A1c remains above goal. Glipizide will improve glycemic control, but it is associated with weight gain that is not in concordance with the patient's desire for continued weight loss.
Basal insulin coverage can be provided with one to two daily injections of insulin detemir, glargine, or neutral protamine Hagedorn (NPH) insulin. Basal insulin may be added to metformin when the hemoglobin A1c level remains above goal. Basal insulin will improve glycemic control, but it is associated with weight gain that is not in concordance with the patient's desire for continued weight loss.