Management of Elevated HbA1c in Patient on Empagliflozin and NPH 70/30 Insulin
The patient should be transitioned from NPH 70/30 insulin to a basal-bolus insulin regimen while maintaining empagliflozin, as the significant HbA1c increase from 7.9% to 9.2% indicates inadequate glycemic control with the current regimen. 1
Assessment of Current Regimen
- The patient's HbA1c has increased significantly from 7.9% to 9.2% over 3 months, indicating inadequate glycemic control with the current regimen of empagliflozin 25mg and NPH 70/30 insulin 1
- Premixed insulin analogues like 70/30 have suboptimal pharmacodynamic profiles for covering postprandial glucose excursions, which may be contributing to the poor control 1
- The current total daily insulin dose of 45 units (25u AM + 10u afternoon + 10u PM) may be insufficient for the patient's needs 2
Recommended Treatment Adjustments
- Maintain empagliflozin 25mg as it has been shown to improve glycemic control and reduce weight without increasing hypoglycemia risk when combined with insulin 3, 4
- Transition from NPH 70/30 to a basal-bolus insulin regimen to better control both fasting and postprandial glucose excursions 1
- Start with a basal insulin (glargine, detemir, or degludec) at approximately 50-60% of the current total daily insulin dose (22-27 units) 1
- Add rapid-acting insulin (lispro, aspart, or glulisine) before meals, starting with 4 units or 10% of the total daily insulin dose before each meal 1, 2
Titration Protocol
- Adjust basal insulin dose by 1-2 units (or 5-10% for higher doses) once or twice weekly until fasting blood glucose reaches target 1
- Titrate prandial insulin doses by 1-2 units twice weekly based on postprandial glucose readings 1, 2
- For any hypoglycemic episodes, reduce the corresponding insulin dose by 10-20% 2
- Self-monitoring of blood glucose should be performed daily during the titration phase 1
Monitoring and Follow-up
- Schedule follow-up within 2-4 weeks to assess response to the new regimen 1
- Provide diabetes education on insulin administration, blood glucose monitoring, and hypoglycemia management 1
- Target an HbA1c of <7.0-7.5% depending on the patient's age and comorbidities 1
- Monitor for signs of hypoglycemia, which is less common with empagliflozin plus insulin compared to insulin alone 3, 4
Benefits of This Approach
- Basal-bolus insulin therapy provides more precise and flexible prandial coverage than premixed insulin 1
- Empagliflozin has been shown to reduce insulin requirements by 9-11 units/day while improving glycemic control 3
- The combination of empagliflozin with insulin results in weight loss of 2.4-2.5 kg compared to insulin alone 3, 4
- This approach addresses both fasting and postprandial hyperglycemia, which are likely contributing to the elevated HbA1c 1
Common Pitfalls to Avoid
- Continuing with premixed insulin despite poor control - premixed insulins have limited flexibility for dose adjustments 1
- Not reducing basal insulin when adding prandial insulin, which increases hypoglycemia risk 1
- Inadequate patient education on the new insulin regimen, which can lead to dosing errors 1
- Delaying insulin regimen intensification despite poor glycemic control, which can lead to prolonged hyperglycemia 1