Is it okay to discontinue Lantus (insulin glargine) and increase Trulicity (dulaglutide) from 1.5mg to 3mg weekly in a male diabetic patient with improved glycemic control?

Managing Diabetes Treatment in a Patient with Improved Glycemic Control

Increasing Trulicity to 3 mg weekly and discontinuing Lantus insulin is appropriate for this patient with significant A1C improvement from 11.2% to 6.2%. 1, 2

Assessment of Current Glycemic Control

The patient has achieved excellent glycemic control with an A1C reduction from 11.2% to 6.2%, which is well below the typical target of 7.0%. This significant improvement indicates that the current regimen may be more intensive than necessary, potentially increasing the risk of hypoglycemia.

Recommended Treatment Modification

Regarding Trulicity (Dulaglutide)

• Increasing Trulicity from 1.5 mg to 3 mg weekly is appropriate and aligns with FDA-approved dosing guidelines 2
• The FDA label for Trulicity states: "If additional glycemic control is needed, increase the dosage in 1.5 mg increments after at least 4 weeks on the current dosage" 2
• Maximum recommended dosage is 4.5 mg injected subcutaneously once weekly 2
• Dulaglutide has demonstrated efficacy in glycemic control comparable to insulin glargine with the added benefits of:
  • Weight loss rather than weight gain 1, 3
  • Lower risk of hypoglycemia 4, 3
  • Once-weekly administration improving adherence 5

Regarding Lantus (Insulin Glargine)

• Discontinuing Lantus is appropriate given:
  1. The excellent A1C of 6.2% (well below target)
  2. The patient is on multiple non-insulin glucose-lowering agents (Trulicity, Jardiance, and metformin)
  3. Continuing basal insulin with the current regimen increases risk of hypoglycemia
  4. The 2023 ADA Standards of Care support deintensification of diabetes treatment when glycemic targets are exceeded 1

Rationale for Treatment Changes

1. Overbasalization risk: The patient's current Lantus dose of 56 units nightly with an A1C of 6.2% suggests possible overbasalization, which the ADA guidelines recommend evaluating and addressing 1

2. Hypoglycemia prevention: The ADA Standards of Care emphasize that "hypoglycemia is the major limiting factor in the glycemic management of type 1 and type 2 diabetes" 1

3. Medication optimization: The 2025 ADA guidelines recommend that "if an individual is not already being treated with a GLP-1 RA, a GLP-1 RA should be considered prior to continuing insulin therapy to address prandial management and to lower the risks of hypoglycemia and weight gain associated with insulin therapy" 1

4. Evidence-based approach: Clinical trials have shown that dulaglutide can effectively replace or reduce insulin requirements while maintaining glycemic control 4, 3, 6

Implementation Plan

1. Increase Trulicity to 3 mg weekly
2. Discontinue Lantus insulin completely
3. Continue Jardiance 25 mg daily and metformin 1000 mg twice daily
4. Monitor blood glucose closely for 1-2 weeks after these changes
5. If fasting blood glucose rises significantly (>180 mg/dL consistently) or A1C increases at follow-up, consider reintroducing a lower dose of Lantus

Monitoring Recommendations

• Check fasting and postprandial glucose levels daily for the first 1-2 weeks after medication changes
• Schedule follow-up within 1 month to assess response to therapy changes
• Recheck A1C in 3 months
• Monitor for signs/symptoms of hyperglycemia
• Educate patient on signs of hyperglycemia that would warrant contacting their provider

Potential Pitfalls to Avoid

• Abrupt insulin discontinuation: While discontinuing Lantus is appropriate in this case, monitor closely for hyperglycemia
• Underestimating GLP-1 RA potency: Trulicity at higher doses can provide significant glucose-lowering effects that may compensate for the removal of basal insulin
• Overlooking patient education: Ensure the patient understands the medication changes and monitoring requirements
• Neglecting to consider type of diabetes: This recommendation assumes type 2 diabetes; if the patient has type 1 diabetes, insulin should not be discontinued

By optimizing this patient's regimen with increased Trulicity and discontinuation of Lantus, we can maintain excellent glycemic control while reducing the risk of hypoglycemia and simplifying the treatment regimen.