Should adjustments be made to the diabetes medication regimen for a patient with an A1C of 9.0%, on Triseba (insulin) 50u daily, Jardiance (empagliflozin) 100mg, and metformin 500mg bid, with FBS in the 130s, hypoglycemic episodes, and taking daily prednisone for arthritis?

Diabetes Medication Adjustments for Patient with A1C 9.0%, Hypoglycemic Episodes, and on Prednisone

The patient's diabetes medication regimen requires adjustment due to the combination of elevated A1C (9.0%), hypoglycemic episodes (50s), and concurrent prednisone therapy for arthritis.

Current Assessment

• Patient is currently on:
  • Tresiba (insulin degludec) 50 units daily
  • Jardiance (empagliflozin) 100mg daily (note: standard dose is 10-25mg)
  • Metformin 500mg twice daily
  • Daily prednisone for arthritis 1
• Current glycemic control:
  • A1C 9.0% (indicating poor overall control)
  • Fasting blood sugars in 130s (relatively acceptable)
  • Episodes of hypoglycemia with readings in the 50s (concerning) 1

Recommended Medication Adjustments

Immediate Concerns

• The Jardiance (empagliflozin) dose of 100mg is significantly higher than the maximum FDA-approved dose of 25mg daily and should be reduced to 25mg daily immediately 2
• Hypoglycemic episodes in the 50s require urgent attention as they represent level 2 hypoglycemia (glucose <54 mg/dL) 1, 3

Insulin Adjustment

• Reduce Tresiba (insulin degludec) dose by 10-20% (to approximately 40-45 units daily) to address the hypoglycemic episodes 1
• Consider morning administration of Tresiba to better counteract the hyperglycemic effect of prednisone, which typically causes glucose elevations later in the day 1, 4
• Monitor fasting glucose levels for 3-7 days after adjustment to ensure values remain in target range (80-130 mg/dL) without hypoglycemia 1

SGLT2 Inhibitor (Jardiance)

• Correct Jardiance dose to 25mg daily (maximum approved dose) 2
• Continue this medication as it provides cardiovascular benefits and can help with weight management 2, 5
• Monitor for genital mycotic infections and urinary tract infections, which are common side effects 2

Metformin

• Increase metformin dose to 1000mg twice daily if tolerated, as the current dose (500mg twice daily) is suboptimal for most adults with type 2 diabetes 4
• This increase may help improve insulin sensitivity and allow for more effective insulin action 4

Monitoring Plan

• Instruct patient to perform self-monitoring of blood glucose (SMBG):
  • Before meals and at bedtime to guide further insulin adjustments 4, 6
  • During times when prednisone effect is expected to be highest (typically afternoon and evening) 4
• Teach patient proper hypoglycemia management:
  • Treat hypoglycemia with 15-20g of glucose when blood glucose is <70 mg/dL 1
  • Recheck in 15 minutes and repeat treatment if still hypoglycemic 1
  • Consume a meal or snack after recovery to prevent recurrence 1
• Prescribe glucagon for emergency use and educate family members on administration 1, 3
• Schedule follow-up in 2-4 weeks to reassess glycemic control and make further adjustments as needed 4

Additional Considerations

• The combination of prednisone and insulin therapy requires careful balance:
  • Prednisone typically causes insulin resistance and hyperglycemia, particularly in the afternoon and evening 4
  • Consider splitting the basal insulin dose or adding a small dose of rapid-acting insulin with lunch/dinner if post-lunch/dinner hyperglycemia persists 4
• If hypoglycemia continues despite insulin dose reduction, consider:
  • Further reducing insulin dose by an additional 10% 1
  • Evaluating the timing of hypoglycemic episodes in relation to meals, exercise, and medication administration 1, 3
• If A1C remains elevated after optimizing current medications, consider:
  • Adding a GLP-1 receptor agonist, which can improve glycemic control while potentially reducing insulin requirements 1, 7
  • Implementing a basal-bolus insulin regimen with small doses of rapid-acting insulin before meals 1