Would adding Jardiance (empagliflozin) be appropriate for a patient with inadequate glycemic control on glipizide and insulin glargine (Lantus) 20 units, with hyperglycemia?

Adding Jardiance to Glipizide and Lantus Regimen for Inadequate Glycemic Control

Yes, adding Jardiance (empagliflozin) is appropriate and recommended for this patient with persistent hyperglycemia on glipizide and Lantus 20 units, as it will improve glycemic control while offering cardiovascular benefits.

Rationale for Adding Jardiance

When basal insulin (Lantus) has been initiated but blood glucose levels remain above target (mid-200s in this case), combination therapy should be considered to improve glycemic control. The American Diabetes Association guidelines support adding an SGLT2 inhibitor like Jardiance to improve glucose control and potentially reduce total daily insulin dose 1.

Current regimen limitations:

• Patient is on a sulfonylurea (glipizide) and basal insulin (Lantus 20 units)
• Blood glucose remains elevated in mid-200s range
• This indicates inadequate control with current therapy

Benefits of Adding Jardiance

1. Glycemic Control

   • Jardiance provides complementary mechanism of action to existing therapy
   • Expected HbA1c reduction of 0.6-0.8% when added to insulin therapy 2
   • Works independently of insulin action by promoting urinary glucose excretion

2. Cardiovascular Benefits

   • Demonstrated cardioprotective properties in patients with established cardiovascular disease 3
   • May reduce cardiovascular mortality

3. Additional Benefits

   • Weight reduction (approximately 2-3% of body weight) 4
   • Blood pressure reduction (systolic BP reduction of ~3-4 mmHg) 4
   • Low risk of hypoglycemia when added to existing regimen 3

Implementation Approach

1. Dosing

   • Start with Jardiance 10 mg once daily
   • Can be increased to 25 mg once daily if needed and tolerated 4
   • Take in the morning regardless of meals

2. Insulin Adjustment

   • Initially maintain current Lantus dose (20 units)
   • Monitor blood glucose closely for 1-2 weeks after starting Jardiance
   • May need to reduce insulin dose by 10-20% if blood glucose improves significantly to avoid hypoglycemia 1

3. Monitoring

   • Check blood glucose daily, especially fasting levels
   • Monitor for symptoms of hypoglycemia
   • Reassess HbA1c after 3 months of therapy

Precautions and Considerations

• Hypoglycemia Risk: While SGLT2 inhibitors themselves have low risk of hypoglycemia, the combination with sulfonylurea (glipizide) and insulin increases this risk 4
• Volume Depletion: Monitor for signs of dehydration, especially in elderly patients
• Genital Infections: Educate patient about increased risk (5-8% incidence) 2
• Urinary Tract Infections: Monitor for symptoms (12-15% incidence) 2
• Diabetic Ketoacidosis (DKA): Rare but serious risk; educate patient about symptoms 4

Common Pitfalls to Avoid

1. Not adjusting insulin dose: Failure to reduce insulin dose if needed after adding Jardiance may lead to hypoglycemia
2. Inadequate hydration: Patients should maintain adequate fluid intake to prevent dehydration
3. Missing early signs of DKA: Be vigilant for symptoms even when blood glucose is not severely elevated
4. Continuing therapy during acute illness: Advise temporary discontinuation during severe illness or surgical procedures

Adding Jardiance to the current regimen of glipizide and Lantus is an evidence-based approach to address inadequate glycemic control while potentially providing cardiovascular benefits and weight reduction.