Date of Award
Doctor of Nursing (ND)
Hector R. Morales, DNP, APRN, PMH/CS-BC
Background: Current guidelines recommend metformin as the first-line agent therapy for the
management of Type 2 Diabetes (T2D) when diet and exercise are insufficient. When
monotherapy with metformin is intolerant or contraindicated, or not sufficiently effective to
reach the glycated hemoglobin (HbA1c) target, a second anti-diabetic agent as an alternative or
add-therapy to metformin is recommended by all guidelines. The quality improvement project
was initiated in the fall semester with a 10-day reflective practice log to assess my current
practice. A review of the clinical practice log allowed for evaluation of my current practice and
identify three opportunities to improve my practice. I developed three potential PICOT questions
and selected one for the QI project with the guidance of my Doctor of Nursing Practice (DNP)
chairperson. I performed a literature review in search of the best evidence-based intervention to
improve my practice. My current practice is metformin 500-1000mg twice daily as a first line
treatment for T2DM. The new evidence-based intervention that I found in the literature review
was to initiate empagliflozin 10-25mg once daily as the first line treatment or as add-on therapy
to metformin in adults 18 to 78 years of age with uncontrolled T2DM. The evidenced based QI
proposal was presented to the Internal Review Board (IRB) at The University of Texas at El Paso
(UTEP) and my worksite manager. An Approval letter was obtained from the IRB at UTEP and
work site manager before initiation of the QI project. The evidence-based QI project was
implemented for six weeks in the Spring semester.
Purpose: This Quality Improvement (QI) project aims to use a sodium-glucose cotransporter 2
(SGLT2) inhibitor alone or in combination with other agents to improve glycemic control in
patients 18 to 78 years of age with uncontrolled T2DM (HbA1c >7%) within 4 weeks.
Methods: The Plan-Do-Study-Act (PDSA) method of quality improvement was used in this
project. Baseline HbA1c levels were recorded at the first visit before initiating the intervention.
Post-intervention HbA1c levels were recorded two weeks after initiating the intervention to
assess its efficacy and tolerance of the new medication. Blood pressure and weight were
recorded on the first visit and after initiating intervention.
Intervention: The SGLT2 inhibitor, empagliflozin was selected as first-line therapy for patients
with new-onset T2DM. Empagliflozin was added as a combination treatment to the drug
regimens of patients who presented with T2DM that was not adequately controlled by
metformin. Inclusion criteria were (1) all patients 18–79 years of age who were (2) newly
diagnosed or presenting with uncontrolled T2DM (HbA1c >7%). Kurt Lewin’s three-step model
was used as the translational theoretic framework for this project. The steps included (1)
Unfreeze (i.e., acknowledging that a change is needed); (2) Change (i.e., initiate treatment with
an SGLT2 inhibitor, and (3) Refreeze (i.e., make the change permanent and continue the patient
on this drug).
Results: Nineteen patients between the ages of 23–78 years old (18 females and one male) were
identified in the QI project. The average reduction in HbA1c levels was 0.21%. Thus, the results
of this project suggested an overall trend toward improvement of glycemic control.
Conclusion: Empagliflozin provided as monotherapy or as an add-on to metformin was effective
at reducing HbA1c to improve glycemic control. Patients treated with empagliflozin also
responded with reduced systolic blood pressure and weight loss
Crespin, Maria, "Empagliflozin and/or Metformin: A Combination Approach for Uncontrolled Type 2 Diabetes" (2022). Cohort X. 17.