From the Guidelines
I strongly recommend adding a long-acting insulin, such as insulin glargine (Lantus) or insulin detemir (Levemir), at a starting dose of 10 units at bedtime to the current regimen of Farsi 10 mg. The patient's persistent hyperglycemia in the mid-200s during afternoons and evenings indicates that the SGLT2 inhibitor alone is insufficient for glycemic control. Long-acting insulin provides 24-hour basal coverage that can help lower overall blood glucose levels, particularly addressing the afternoon and nighttime hyperglycemia 1.
The patient should monitor blood glucose levels before breakfast and dinner daily, aiming for target ranges of 80-130 mg/dL fasting and <180 mg/dL postprandial. The insulin dose can be titrated by increasing by 2 units every 3 days until fasting glucose targets are achieved, as recommended by the 2025 standards of care in diabetes 1. Additionally, the patient should maintain consistent carbohydrate intake, particularly at dinner, to prevent nocturnal hypoglycemia.
Some key points to consider when initiating insulin therapy include:
- Starting with a low dose and titrating up to achieve target glucose levels
- Monitoring for signs of hypoglycemia and adjusting the dose accordingly
- Maintaining a consistent carbohydrate intake to prevent nocturnal hypoglycemia
- Considering the use of a GLP-1 RA or dual GIP and GLP-1 RA in combination with insulin if A1C remains above goal 1
It is also important to note that lifestyle modifications, such as a healthy diet and regular physical activity, can help improve glycemic control and should be encouraged in conjunction with medication therapy 1. However, in this case, the patient's hyperglycemia is not adequately controlled with the current regimen, and the addition of long-acting insulin is necessary to achieve better glycemic control.
From the Research
Recommendation for Additional Medication or Changes to Diabetic Regimen
The patient is currently taking Farsi 10 mg and has a large QHS with hyperglycemia, with blood glucose levels in the low to mid 200s in the afternoon and at night.
- The patient's current regimen may need to be adjusted to achieve better glycemic control.
- According to the study 2, basal-bolus plus correction insulin therapy is preferred for managing hyperglycemia in hospitalized patients.
- The study 3 suggests that adding other antidiabetes medications to insulin can improve glycemic control and potentially lower the required insulin dose, resulting in less weight gain and lower risk for hypoglycemia.
- The study 4 found that dipeptidyl peptidase-4 (DPP-4) inhibitors, such as sitagliptin and saxagliptin, can improve β-cell function and increase insulin secretion when used in combination with other antidiabetic agents.
- The study 5 compared the effects of metformin and sulphonylurea combination therapy with other antidiabetic medications and found that the combination therapy was associated with a higher risk of hypoglycemia.
- The study 6 recommends a blood glucose target range of 140-180 mg/dL for hospitalized patients receiving artificial nutrition and suggests using a diabetes-specific enteral nutrition formula, lowering the dextrose content, and using a hypocaloric parenteral nutrition formula to prevent hyperglycemia.
Potential Changes to the Patient's Regimen
- Consider adding a DPP-4 inhibitor, such as sitagliptin or saxagliptin, to the patient's regimen to improve β-cell function and increase insulin secretion.
- Adjust the patient's insulin regimen to a basal-bolus plus correction regimen, as recommended by the study 2.
- Monitor the patient's blood glucose levels closely and adjust the regimen as needed to achieve a target range of 140-180 mg/dL.
- Consider using a diabetes-specific enteral nutrition formula, lowering the dextrose content, and using a hypocaloric parenteral nutrition formula to prevent hyperglycemia, as recommended by the study 6.