What type of insulin should a patient with type 2 diabetes (T2D) on Farxiga (dapagliflozin) start using after experiencing hyperglycemia due to prednisone?

Insulin Selection for Type 2 Diabetes Patient on Dapagliflozin with Prednisone-Induced Hyperglycemia

For a patient with type 2 diabetes on Farxiga (dapagliflozin) experiencing hyperglycemia due to prednisone, basal insulin with prandial coverage is the most appropriate regimen, specifically using NPH insulin in the morning with rapid-acting insulin before meals.

Understanding Prednisone-Induced Hyperglycemia

Prednisone causes a specific pattern of hyperglycemia that requires targeted insulin therapy:

• Prednisone primarily elevates blood glucose between midday and midnight 1
• This pattern differs from typical hyperglycemia in type 2 diabetes
• Standard basal insulin regimens may not adequately address this pattern

Optimal Insulin Selection

Basal Insulin Component

• NPH insulin (intermediate-acting) is preferred over long-acting analogs for prednisone-induced hyperglycemia
  • NPH's peak action better matches the daytime hyperglycemia caused by morning prednisone doses 1
  • Morning administration of NPH provides coverage during the peak hyperglycemic effect of prednisone
  • Long-acting analogs like glargine may cause nocturnal hypoglycemia while undertreatting daytime hyperglycemia 1

Prandial Insulin Component

• Rapid-acting insulin analogs (lispro, aspart, or glulisine) should be added before meals
  • These provide better postprandial glucose control than regular human insulin 2
  • Can be dosed immediately before meals for better convenience 2
  • Particularly important for managing the postprandial spikes common with steroid therapy

Dosing Considerations

1. Initial dosing:

   • Start with 0.5 units/kg/day total insulin if insulin-naïve 1
   • If already on insulin, increase the pre-prednisone dose by >30% 1
   • Distribute approximately 50-60% as NPH in the morning and remainder as prandial insulin

2. Titration strategy:

   • Monitor blood glucose frequently, especially midday to evening
   • Adjust NPH dose based on afternoon/evening glucose patterns
   • Adjust prandial insulin doses based on pre-meal and 2-hour post-meal readings

3. Dapagliflozin considerations:

   • Continue dapagliflozin as it works synergistically with insulin 3, 4
   • Dapagliflozin helps reduce total insulin requirements and mitigates weight gain 4
   • Monitor for genital infections and urinary tract infections, which occur more frequently with combined therapy 3, 4

Monitoring and Adjustment

• Assess adequacy of therapy after 3 months 5
• If targets not achieved, consider increasing insulin doses or adjusting the ratio of basal to prandial insulin
• As prednisone is tapered, insulin doses will need to be reduced proportionally to avoid hypoglycemia
• Consider continuous glucose monitoring if available to better visualize glucose patterns 2

Common Pitfalls to Avoid

1. Using only long-acting basal insulin (glargine/detemir) which may not match the prednisone-induced glucose pattern
2. Inadequate prandial coverage - prednisone significantly impacts postprandial glucose
3. Failure to adjust insulin when prednisone doses change - insulin needs decrease as prednisone is tapered
4. Overlooking the continued benefit of dapagliflozin - maintain SGLT2 inhibitor therapy as it complements insulin action 2
5. Therapeutic inertia - delaying insulin intensification when targets aren't met 5

Follow-up Recommendations

• Schedule follow-up within 2 weeks for initial insulin adjustment
• Monthly visits until stable glycemic control is achieved
• Educate patient on hypoglycemia recognition and management
• Consider simplifying regimen once glucose toxicity resolves and as prednisone is tapered

This approach specifically addresses the temporal pattern of prednisone-induced hyperglycemia while maintaining the benefits of the patient's existing dapagliflozin therapy.