Can Jardiance (Empagliflozin) and Lantus (Insulin Glargine) be given together to a patient with poorly controlled diabetes (Hemoglobin A1c elevation) and hypertension?

Jardiance and Lantus Combination Therapy for Elderly Patient with Poorly Controlled Diabetes and Hypertension

Yes, Jardiance (empagliflozin) and Lantus (insulin glargine) can be safely and effectively given together for a 75-year-old female patient with HbA1c of 11 and hypertension. This combination addresses both glycemic control and offers cardiovascular and renal benefits.

Rationale for Combination Therapy

• With an HbA1c of 11%, this patient has severely uncontrolled diabetes requiring aggressive therapy. At this level, combination therapy is strongly indicated rather than monotherapy 1, 2.
• Insulin therapy (Lantus) is appropriate for patients with significantly elevated HbA1c (>9%), especially in elderly patients who need reliable glucose reduction 1, 2.
• Adding Jardiance (empagliflozin) to insulin therapy provides complementary mechanisms of action and additional benefits beyond glycemic control 1, 3.

Benefits of This Combination

• Glycemic Control Benefits:

  • Lantus (insulin glargine) provides reliable, dose-dependent glucose reduction necessary for severely elevated HbA1c 1.
  • Empagliflozin works through an insulin-independent mechanism, reducing glucose reabsorption in the kidneys 1.
  • The combination can achieve greater HbA1c reduction than either agent alone 1, 2.

• Cardiovascular and Renal Benefits:

  • Empagliflozin has demonstrated cardiovascular and renal benefits in patients with established cardiovascular disease or at high risk 1, 3.
  • This is particularly important for this elderly patient with hypertension, who has increased cardiovascular risk 4.
  • Empagliflozin can help reduce blood pressure, providing additional benefit for the patient's hypertension 1, 3.

Precautions and Monitoring

• Hypoglycemia Risk:

  • When adding empagliflozin to insulin therapy, consider reducing the insulin dose by 10-20% initially to avoid hypoglycemia 1.
  • More frequent blood glucose monitoring should be implemented during the initial combination period 1.

• Renal Function:

  • Monitor renal function before and periodically during treatment, as empagliflozin is not recommended when eGFR falls below 45 mL/min/1.73m² 1.
  • For patients treated with empagliflozin, serum creatinine/eGFR and potassium levels should be monitored at least annually 1.

• Volume Status:

  • Elderly patients are more susceptible to volume depletion. Monitor for signs of dehydration, especially when used with diuretics 1.
  • Empagliflozin should be used with caution when combined with diuretics and/or ACE inhibitors due to increased risk of dehydration and orthostatic hypotension 1.

• Diabetic Ketoacidosis (DKA):

  • Educate the patient about the rare risk of euglycemic DKA with SGLT2 inhibitors and advise to seek immediate care if symptoms develop (nausea, vomiting, abdominal pain) 1.

Dosing Considerations

• Start with a lower dose of empagliflozin (10mg daily) and titrate as needed 1.
• Adjust insulin dosing based on blood glucose monitoring results, with close follow-up during the initial combination period 1.
• Consider the patient's renal function when determining the appropriate empagliflozin dose 1.

Additional Management Considerations

• Lifestyle modifications remain important, including dietary changes, sodium restriction, and physical activity appropriate for an elderly patient 1.
• Regular monitoring of blood pressure is essential, with a target of <140/90 mmHg for this elderly patient with diabetes 1.
• Consider adding or optimizing antihypertensive therapy if blood pressure remains uncontrolled despite the addition of empagliflozin 1.

This combination therapy addresses both the immediate need for glycemic control and provides additional cardiovascular and renal protection, making it an appropriate choice for this elderly patient with poorly controlled diabetes and hypertension.