From the Guidelines
For a patient with an HbA1c of 9% on Lantus 40 units daily, Novolog 9 units TID, Farxiga, and Metformin, I recommend increasing the total daily insulin dose by approximately 10-20% as per the latest guidelines 1. Specifically, increase Lantus by 4-8 units (to 44-48 units daily) and consider increasing Novolog by 1-2 units per meal (to 10-11 units TID) based on the patient's blood glucose patterns and response to therapy. This adjustment should be made gradually, starting with the basal insulin (Lantus) first, then adjusting the mealtime insulin (Novolog) as needed. The patient should monitor blood glucose levels more frequently after making these changes, particularly watching for hypoglycemia. An HbA1c of 9% indicates average blood glucose levels of approximately 212 mg/dL, which is significantly above the target range of less than 7% (estimated average glucose of 154 mg/dL). The insulin dose adjustment aims to lower blood glucose levels while the oral medications (Farxiga and Metformin) continue to work through complementary mechanisms - Metformin decreasing hepatic glucose production and improving insulin sensitivity, while Farxiga promotes urinary glucose excretion. Key considerations in adjusting insulin doses include the patient's weight, activity level, and dietary habits, as well as the presence of any comorbid conditions that may affect glucose metabolism or insulin sensitivity 1. Regular follow-up and monitoring of blood glucose levels and HbA1c are crucial to assess the effectiveness of the adjusted insulin regimen and make further adjustments as needed to achieve optimal glycemic control.
From the Research
Insulin Dose Adjustment
To determine the recommended increase in insulin dose for a patient with HbA1c of 9% on Lantus (insulin glargine) 40 units, Novolog (insulin aspart) 9 units TID, Farxiga (dapagliflozin), and Metformin (metformin), consider the following:
- The American Association of Clinical Endocrinologists and the American Diabetes Association recommend considering insulin administration for people with type 2 diabetes with HbA1c levels exceeding 9.0% and 10%, respectively 2.
- A study comparing basal insulin directly with glucagon-like peptide-1 (GLP-1) receptor agonists suggests that the latter agents may offer superior benefit 2.
- Short-term intensive insulin therapy could be the preferred option for new onset Type 2 diabetes mellitus patients with HbA1c >9 3.
Factors to Consider
When adjusting the insulin dose, consider the following factors:
- Current HbA1c level: 9% indicates that the patient's blood glucose levels are not well-controlled.
- Current insulin regimen: Lantus 40 units and Novolog 9 units TID.
- Presence of other medications: Farxiga and Metformin.
- Patient's lifestyle and health status.
Recommendations
Based on the available evidence, the following recommendations can be made:
- Consider increasing the insulin dose to achieve better glycemic control.
- The increase in insulin dose should be individualized based on the patient's response to therapy and their lifestyle.
- Consider using a treatment algorithm, such as the FullSTEP, SimpleSTEP, ExtraSTEP, or AUTONOMY algorithms, to guide the intensification of therapy 4.
- Monitor the patient's blood glucose levels and adjust the insulin dose accordingly.
Potential Increase in Insulin Dose
The potential increase in insulin dose will depend on the patient's individual response to therapy and their lifestyle. However, based on the available evidence, the following increases in insulin dose could be considered:
- Increase the Lantus dose by 10-20% every 3-4 days until the patient's blood glucose levels are well-controlled.
- Increase the Novolog dose by 1-2 units every 3-4 days until the patient's blood glucose levels are well-controlled.
- Consider adding a new insulin or adjusting the current insulin regimen to achieve better glycemic control.