How should the regimen be adjusted for a patient with hyperglycemia, currently on Humulin (insulin) 70/30, 17 units twice daily (BID), and Jardiance (empagliflozin) 50 mg daily, with an elevated Hemoglobin A1c (HbA1c) level?

Management of Severe Hyperglycemia with A1c 13.4%

For a patient with an A1c of 13.4% on Humulin 70/30 17 units BID and Jardiance 50 mg daily, the regimen should be intensified to a basal-bolus insulin regimen while correcting the Jardiance dose to the maximum FDA-approved dose of 25 mg daily.

Current Medication Assessment

• Humulin 70/30: A premixed insulin containing 70% NPH (intermediate-acting) and 30% regular insulin (short-acting)

  • Current dose: 17 units twice daily
  • This provides both basal and prandial coverage but in a fixed ratio that cannot be individually adjusted

• Jardiance (empagliflozin):

  • Current dose: 50 mg daily
  • FDA-approved maximum dose is 25 mg daily 1
  • Overdosing without additional benefit

Recommended Treatment Adjustments

1. Correct SGLT2 Inhibitor Dosing

• Reduce Jardiance to 25 mg daily (maximum FDA-approved dose)
• Higher doses have not shown additional benefit but may increase side effect risk

2. Insulin Intensification

• Convert to basal-bolus insulin regimen:

  • With A1c >10%, insulin intensification is strongly recommended 2
  • The current regimen shows signs of overbasalization with inadequate prandial coverage

• Initial basal insulin dose:

  • Calculate 80% of total current daily insulin dose (34 units)
  • Basal component: ~27 units total
  • Consider long-acting insulin analog (glargine, detemir) once daily

• Add prandial insulin:

  • Start with rapid-acting insulin before meals
  • Initial dose: 4 units or 10% of basal dose with each meal 2
  • Titrate by 1-2 units or 10-15% twice weekly based on post-meal glucose readings

3. Consider Adding GLP-1 Receptor Agonist

• Adding a GLP-1 RA to insulin therapy is recommended for greater efficacy and durability of treatment effect 2
• This combination has shown superior glycemic control compared to insulin intensification alone 3
• Can help reduce total insulin requirements and minimize weight gain

Monitoring and Follow-up

1. Blood glucose monitoring:

   • Fasting and pre-meal: Target 80-130 mg/dL
   • 2-hour post-meal: Target <180 mg/dL
   • Monitor for hypoglycemia, especially overnight

2. Insulin titration:

   • Adjust basal insulin based on fasting glucose
   • Adjust prandial insulin based on post-meal glucose excursions
   • Evaluate for signs of overbasalization (basal dose >0.5 units/kg/day, high bedtime-morning glucose differential) 2

3. Follow-up timing:

   • Schedule follow-up within 1-2 weeks to assess response
   • Check A1c in 3 months

Important Considerations and Pitfalls

1. Risk of diabetic ketoacidosis (DKA):

   • SGLT2 inhibitors can mask hyperglycemia while still allowing ketosis
   • Educate patient on DKA symptoms and ketone monitoring

2. Hypoglycemia risk:

   • More intensive insulin regimens increase hypoglycemia risk
   • Ensure patient has glucagon available and knows how to manage low blood glucose

3. Common errors to avoid:

   • Continuing fixed-ratio insulin when individualized basal-bolus is needed
   • Maintaining excessive SGLT2 inhibitor dosing (>25 mg Jardiance)
   • Delaying treatment intensification with severe hyperglycemia (A1c >10%)

4. Patient education:

   • Provide diabetes self-management education on insulin administration, glucose monitoring, hypoglycemia management, and sick day rules 2

This approach prioritizes rapid improvement in glycemic control to reduce the risk of diabetes complications while minimizing hypoglycemia risk through careful insulin titration and consideration of combination therapy.