What is the best treatment plan for a patient with uncontrolled type 2 diabetes mellitus (T2DM) with hyperglycemia, who has a history of insulin use, and is currently being treated for acute urinary tract infection (UTI), diabetic polyneuropathy, and chronic gastritis, considering the use of Lantus (insulin glargine) and Farxiga (dapagliflozin)?

Treatment Plan for Uncontrolled Type 2 Diabetes with Multiple Comorbidities

For a patient with uncontrolled type 2 diabetes mellitus with hyperglycemia who previously used insulin, the optimal treatment plan is to restart insulin therapy with Lantus (insulin glargine) once daily and add Farxiga (dapagliflozin), while continuing current treatments for comorbidities.

Assessment of Current Status

The patient presents with:

• Uncontrolled type 2 diabetes mellitus with hyperglycemia
• History of insulin use (8 months ago)
• Current acute UTI (being treated with Macrobid)
• Diabetic polyneuropathy (being treated with Gabapentin)
• Chronic gastritis (being treated with Omeprazole)
• Chronic diarrhea (under investigation)

Diabetes Management Plan

Step 1: Initiate Basal Insulin

• Start Lantus (insulin glargine) at 10 units or 0.1-0.2 units/kg once daily in the evening 1
• Titration algorithm:
  • Adjust dose every 3-7 days based on fasting blood glucose (FBG) readings
  • Increase by 2 units if FBG ≥100-120 mg/dL
  • Increase by 4 units if FBG ≥120-140 mg/dL
  • Increase by 6-8 units if FBG ≥140 mg/dL 2
  • Target FBG <100 mg/dL to achieve HbA1c <7% 3

Step 2: Add SGLT2 Inhibitor

• Add Farxiga (dapagliflozin) 10 mg once daily 4
• Benefits:
  • Improves glycemic control independent of insulin action
  • Promotes weight loss (1-2 kg over placebo)
  • Reduces cardiovascular risk 1, 5
  • May allow for eventual reduction in insulin requirements 6

Step 3: Monitoring and Follow-up

• Check HbA1c in 3 months after treatment intensification 3
• Monitor for urinary tract infections and genital infections (more common with SGLT2 inhibitors) 6
• Evaluate renal function regularly (eGFR and serum creatinine)
• Standard target HbA1c <7% for most non-pregnant adults 3

Rationale for Treatment Selection

1. Why Insulin Therapy?

   • The patient has uncontrolled hyperglycemia and previously used insulin
   • Insulin should be used when patients are not achieving glycemic goals with oral agents 1
   • Basal insulin (Lantus) provides stable 24-hour coverage with lower risk of nocturnal hypoglycemia compared to NPH insulin 7

2. Why Farxiga (dapagliflozin)?

   • SGLT2 inhibitors have shown cardiovascular benefits in patients with T2DM 1
   • Works via an insulin-independent mechanism by reducing renal glucose reabsorption 5, 8
   • Complementary to insulin therapy with minimal hypoglycemia risk 6
   • Can be safely combined with insulin, with studies showing improved glycemic control over 104 weeks 6

3. Why This Combination?

   • The ADA/EASD consensus recommends combining injectable medications with oral agents when glycemic targets are not achieved 1
   • This approach addresses multiple pathophysiologic defects in T2DM
   • The combination has shown efficacy in reducing HbA1c without increasing major hypoglycemic episodes 6

Important Considerations and Precautions

For Insulin Therapy

• Risk of hypoglycemia: Educate patient on recognition and management
• Weight gain: Mitigated by concurrent use of dapagliflozin
• Start at a lower dose (10 units) and titrate gradually to minimize hypoglycemia risk 1

For Dapagliflozin

• Increased risk of genital infections and UTIs: Monitor closely, especially since patient is currently being treated for UTI 6
• Wait until current UTI resolves before starting dapagliflozin
• Avoid in patients with eGFR <45 mL/min/1.73m²
• May cause mild volume depletion: Monitor for orthostatic hypotension

Drug Interactions

• No significant interactions between insulin glargine, dapagliflozin, and the patient's current medications (Macrobid, Gabapentin, Omeprazole)

Alternative Approaches

If the patient has contraindications to SGLT2 inhibitors:

• Consider GLP-1 receptor agonists as an alternative to or in combination with basal insulin 1
• Benefits include weight loss and lower hypoglycemia risk compared to increasing insulin doses 3

If the patient has contraindications to insulin:

• Consider combination oral therapy with metformin plus additional agents
• However, given the uncontrolled hyperglycemia and previous insulin use, insulin therapy is likely necessary 1