From the Guidelines
For a patient experiencing hyperglycemia with afternoon and evening blood glucose levels in the low to mid 200s while on Farxiga 10 mg and glargine at bedtime, I recommend adding a mealtime insulin such as insulin lispro (Humalog) or insulin aspart (NovoLog) before lunch and dinner, starting at 4 units per meal and titrating up by 1-2 units every 3 days until afternoon and evening glucose levels are below 180 mg/dL. This approach is supported by the American Diabetes Association standards of medical care in diabetes, which suggest that when basal insulin has been titrated to appropriate fasting blood glucose levels but the HbA1c level remains above target, combination injectable therapy should be considered to reduce postprandial glucose excursions 1. The use of a GLP-1 receptor agonist like semaglutide (Ozempic) 0.25 mg weekly for 4 weeks, then increasing to 0.5 mg weekly, could also be considered as an alternative to address the postprandial hyperglycemia 1. Another option is to increase the basal insulin glargine dose by 2-4 units while monitoring for nocturnal hypoglycemia, as basal insulin may be initiated at 10 units or 0.1 to 0.2 units/kg of body weight and titrated accordingly 1. Key considerations in managing hyperglycemia include:
- Monitoring blood glucose levels before meals and at bedtime daily during medication adjustments
- Adjusting insulin doses based on self-monitoring of blood glucose levels
- Balancing the anticipated glucose-lowering effects with the convenience of the regimen and the patient's specific therapy goals
- Providing proper patient education regarding glucose monitoring, insulin injection technique, and recognition/treatment of hypoglycemia 1. The goal of these recommendations is to target postprandial hyperglycemia, which appears to be the main issue since the current regimen (SGLT2 inhibitor and basal insulin) is not controlling afternoon and evening glucose levels.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Recommendations for Additional Medication or Changes to Diabetic Regimen
The patient is currently taking Farxiga 10 mg and glargine QHS, but is experiencing hyperglycemia with blood glucose levels in the low to mid 200s in the afternoon and at night.
- Based on the study 2, adding dapagliflozin to the patient's current regimen may help reduce blood glucose levels and improve glycemic variability.
- The study 3 suggests that adding a GLP-1 receptor agonist, such as albiglutide, to the patient's basal insulin regimen may provide an alternative to prandial insulin and result in comparable HbA1c reduction with weight loss and lower hypoglycemia risk.
- Another option could be to add saxagliptin to the patient's regimen, as the study 4 found that dapagliflozin plus saxagliptin achieved glycemic control similar to basal insulin in patients with type 2 diabetes poorly controlled by metformin.
- The study 5 compared biphasic insulin aspart and insulin glargine administered with oral antidiabetic drugs in type 2 diabetes mellitus, and found that biphasic insulin aspart reduced HbA1c level more efficiently than insulin glargine.
- The study 6 found that insulin degludec/aspart may provide adequate glycemic control and prevent hypoglycemia events compared to insulin glargine, but may be prone to serious adverse events.
Potential Changes to the Patient's Regimen
- Increase the dose of glargine QHS to better control nocturnal glucose levels
- Add a GLP-1 receptor agonist, such as albiglutide, to the patient's basal insulin regimen
- Add dapagliflozin to the patient's current regimen to reduce blood glucose levels and improve glycemic variability
- Add saxagliptin to the patient's regimen to achieve glycemic control similar to basal insulin
- Consider switching to insulin degludec/aspart to provide adequate glycemic control and prevent hypoglycemia events