What are the monitoring parameters for a patient on Farxiga (dapagliflozin), Metformin, Lantus (insulin glargine) and insulin lispro?

Monitoring Parameters for Patients on Farxiga, Metformin, Lantus, and Insulin Lispro

Patients on Farxiga (dapagliflozin), Metformin, Lantus (insulin glargine), and insulin lispro require comprehensive monitoring of blood glucose, renal function, and specific medication-related parameters to ensure safety and optimize glycemic control.

Blood Glucose Monitoring

Self-Monitoring of Blood Glucose (SMBG)

• For patients on multiple daily insulin injections (basal Lantus + prandial lispro):
  • Test before meals and at bedtime daily 1
  • Test 1-2 hours after meals to assess postprandial control 1
  • Occasional 3 AM testing to detect nocturnal hypoglycemia 1

Continuous Glucose Monitoring (CGM)

• Preferred method for patients on intensive insulin therapy 1
• Target: 70% or more time within 70-180 mg/dL (3.9-10.0 mmol/L) range 1
• Assess glycemic variability using standard deviation and coefficient of variation 1

Hemoglobin A1c

• Check every 3 months until stable, then at least twice yearly if stable 2
• Target: Individualized based on patient factors (typically <7.0%) 2

Medication-Specific Monitoring

Farxiga (Dapagliflozin)

• Renal function: Monitor eGFR before initiation and periodically thereafter 2
  • Farxiga can be initiated at eGFR ≥25 mL/min/1.73 m² 2
  • May continue at 10 mg daily if eGFR declines below initiation threshold, until dialysis 2
• Volume status: Assess for signs of dehydration, hypotension, or orthostatic hypotension 3
  • Higher risk in elderly patients, those on loop diuretics, and those with moderate renal impairment 3
• Genital mycotic infections: Monitor for symptoms (more common in females and those with prior history) 3
• Diabetic ketoacidosis (DKA): Monitor for symptoms even with normal or minimally elevated blood glucose 2
  • Consider blood/urine ketone testing during acute illness 2

Metformin

• Renal function: Monitor eGFR before initiation and periodically thereafter 2
  • Reduce dose to 1000 mg/day when eGFR 30-44 mL/min/1.73 m² 2
  • Contraindicated when eGFR <30 mL/min/1.73 m² 2
• Vitamin B12 levels: Consider periodic monitoring, especially in patients with anemia or peripheral neuropathy 2

Insulin (Lantus and Lispro)

• Hypoglycemia: Monitor for symptoms and frequency of events 1
  • Define hypoglycemia as blood glucose <70 mg/dL (<3.9 mmol/L) 1
  • Increased risk when combined with sulfonylureas 3
• Insulin site reactions: Inspect injection sites for lipodystrophy or lipohypertrophy 2
• Insulin storage: Ensure proper storage (refrigeration for unopened vials, room temperature for in-use insulin) 2

Comprehensive Monitoring Schedule

At Every Visit

• Blood pressure and heart rate (especially important with Farxiga) 2
• Weight (expect weight loss with Farxiga, potential weight gain with insulin) 3
• Review of SMBG/CGM data and hypoglycemic episodes 1
• Injection site examination 2
• Foot examination 2

Every 3-6 Months

• HbA1c 2
• Renal function (eGFR, serum creatinine) 2
• Electrolytes 2

Annually

• Comprehensive foot examination 2
• Eye examination 2
• Lipid profile 2
• Liver function tests 2
• Urinary albumin-to-creatinine ratio 2
• Vitamin B12 levels (for long-term metformin users) 2

Medication Adjustment Guidelines

Insulin Adjustment

• Basal insulin (Lantus):

  • Adjust based on fasting glucose values 2
  • If 50% of pre-meal glucose values over 2 weeks are above target (5.0-8.3 mmol/L), increase by 2 units 1
  • If >2 pre-meal glucose values/week are <5.0 mmol/L, decrease dose 1

• Bolus insulin (Lispro):

  • Adjust based on pre-meal and post-meal glucose values 2
  • Administer immediately before meals 2

Common Pitfalls to Avoid

1. Overlooking volume depletion with Farxiga: Monitor closely in elderly patients and those on diuretics 3
2. Missing euglycemic DKA with Farxiga: Remember ketoacidosis can occur with minimal hyperglycemia 2
3. Continuing Metformin despite declining renal function: Adjust dose or discontinue based on eGFR 2
4. Inadequate monitoring for hypoglycemia: Especially important when combining insulin with Farxiga 3
5. Improper insulin storage: Can lead to reduced efficacy 2
6. Overlooking genital mycotic infections: Common side effect of Farxiga requiring prompt treatment 3

By implementing this comprehensive monitoring approach, clinicians can optimize glycemic control while minimizing the risk of adverse events in patients on this combination therapy.