What are the treatment recommendations for a patient with an Hemoglobin A1c (HbA1c) of 10.1%, taking Lantus (insulin glargine) 20 units at bedtime, Jardiance (empagliflozin) 25mg, and metformin 1000mg twice daily, who cannot afford a Glucagon-like peptide-1 (GLP-1) receptor agonist?

Treatment Recommendations for Patient with A1c 10.1% on Lantus, Jardiance, and Metformin

For a patient with an A1c of 10.1% on Lantus 20 units at bedtime, Jardiance 25mg, and metformin 1000mg twice daily who cannot afford GLP-1 receptor agonists, the most appropriate next step is to add prandial insulin, starting with one injection at the largest meal. 1

Current Regimen Assessment

• Patient is on appropriate medications but with inadequate glycemic control (A1c 10.1%) 1
• Current therapy includes:
  • Basal insulin: Lantus 20 units at bedtime
  • SGLT2 inhibitor: Jardiance (empagliflozin) 25mg daily (maximum dose)
  • Metformin: 1000mg twice daily (appropriate dose)
• GLP-1 receptor agonist would be ideal but is not affordable for this patient 1

Recommended Treatment Intensification

Step 1: Assess Basal Insulin Adequacy

• Evaluate if current basal insulin dose is appropriate (current dose 20 units) 1
• Consider if dose is adequate based on:
  • Patient weight (if >0.5 units/kg/day, may indicate overbasalization)
  • Presence of hypoglycemia
  • Glucose variability patterns 1

Step 2: Add Prandial Insulin

• Initiate prandial insulin with one dose at the largest meal or meal with greatest postprandial glucose excursion 1
• Starting dose: 4 units or 10% of basal insulin dose (approximately 2 units) 1
• Consider reducing basal insulin dose by 10% if A1c <8% (not applicable for this patient with A1c 10.1%) 1

Step 3: Titration Protocol

• Increase prandial insulin dose by 1-2 units or 10-15% twice weekly based on postprandial glucose readings 1
• For hypoglycemia: determine cause and reduce corresponding dose by 10-20% if no clear reason 1

Step 4: Further Intensification if Needed

• If A1c remains above target after 3 months, consider:
  • Adding additional prandial insulin injections at other meals (stepwise approach) 1
  • Progress to full basal-bolus regimen if necessary 1

Practical Considerations

• Maintain current SGLT2 inhibitor (Jardiance) and metformin therapy 1

  • These provide complementary mechanisms to insulin
  • SGLT2 inhibitors help reduce total daily insulin requirements and provide cardiovascular benefits 1

• Patient education is critical:

  • Self-monitoring of blood glucose (SMBG) before meals and at bedtime 1
  • Recognition and management of hypoglycemia 1
  • Insulin injection technique 1

Alternative Options if Prandial Insulin Not Acceptable

• Consider twice-daily premixed insulin instead of basal-bolus regimen if simplicity is needed 1
• If available, consider more affordable insulin options (e.g., human insulin vs. analogs) 1
• Maximize current oral therapy doses if not already at maximum 1

Monitoring and Follow-up

• Reassess glycemic control in 2-3 months 1
• Monitor for hypoglycemia, especially as insulin doses are increased 1
• Evaluate weight changes, as insulin intensification may cause weight gain 1

Important Caveats

• Avoid therapeutic inertia - treatment intensification should not be delayed when A1c is significantly above target (10.1%) 1
• Consider insulin dose titration algorithms that patients can implement themselves based on SMBG readings 1
• If patient develops frequent hypoglycemia, consider switching from evening to morning basal insulin dosing 1