What is the management plan for a patient taking Jardiance (Empagliflozin), Novolog 70/30 (Insulin Aspart 70/30), and Lantus (Insulin Glargine) for type 2 diabetes?

Management Plan for a Patient on Jardiance, Novolog 70/30, and Lantus

For patients taking Jardiance (empagliflozin), Novolog 70/30 (insulin aspart 70/30), and Lantus (insulin glargine), the optimal management approach requires careful coordination of these medications to prevent hypoglycemia while achieving glycemic targets.

Insulin Regimen Optimization

• Lantus (insulin glargine) should be administered once daily at the same time each day to provide consistent 24-hour basal insulin coverage 1, 2
• Novolog 70/30 should be administered twice daily, 30 minutes before breakfast and dinner, to provide both immediate and extended glucose control 3, 4
• The combination of these insulins requires careful monitoring as there may be overlapping insulin action between the protamine component of Novolog 70/30 and Lantus 3
• Initial dosing of Lantus should be 10 units or 0.1-0.2 units/kg of body weight, while Novolog 70/30 should start at 10 units or 0.1-0.2 units/kg divided into two equal doses 3, 4

Dose Titration Protocol

• For Lantus: Adjust dose by 2 units every 3 days based on fasting plasma glucose readings, aiming for a target of <100 mg/dL 3, 5
• For Novolog 70/30: Titrate morning and evening doses separately based on pre-lunch and bedtime glucose readings, respectively 4, 6
• If hypoglycemia occurs, reduce the insulin dose by 10-20% and reassess 4
• Regular monitoring of both fasting and postprandial glucose levels is essential, with HbA1c evaluated every 2-3 months 3

Role of Jardiance (Empagliflozin)

• Continue Jardiance as it works through an insulin-independent mechanism to improve glycemic control 7, 8
• Jardiance provides additional benefits including modest weight reduction, blood pressure lowering, and cardioprotective effects 7, 8
• The combination of Jardiance with insulin therapy may allow for lower insulin doses while maintaining glycemic control 3, 8

Potential Concerns and Monitoring

• The risk of hypoglycemia increases when using multiple insulin formulations, requiring careful glucose monitoring 3
• Monitor for signs of diabetic ketoacidosis, particularly during illness or reduced food intake, as SGLT2 inhibitors like Jardiance can increase this risk 8
• Assess renal function regularly as both insulin dosing and Jardiance efficacy are affected by kidney function 7, 8
• Evaluate for signs of lipodystrophy and rotate injection sites to maintain consistent insulin absorption 1

Patient Education

• Provide comprehensive education on glucose monitoring, insulin injection technique, insulin storage, and hypoglycemia recognition/treatment 9
• Instruct patients on "sick day" rules, particularly regarding continued Jardiance use during illness 9, 3
• Emphasize the importance of consistent meal timing and carbohydrate content when using fixed-ratio insulins like Novolog 70/30 4, 6
• Teach patients to recognize and manage the overlapping effects of their medications 3

Treatment Intensification or Simplification

• If glycemic targets are not achieved with the current regimen, consider switching to a more intensive basal-bolus regimen with multiple daily injections of rapid-acting insulin 3
• For patients with good control, consider simplifying the regimen by potentially eliminating one of the insulin formulations (either using only Lantus with mealtime rapid-acting insulin or transitioning completely to Novolog 70/30 twice daily) 3, 4
• Maintain Jardiance therapy regardless of insulin regimen changes due to its cardiovascular and renal benefits 8

Lifestyle Considerations

• Diet, exercise, and education remain the foundation of any type 2 diabetes treatment program, even with complex insulin regimens 9
• Encourage consistent carbohydrate intake at meals to match the fixed-ratio insulin (Novolog 70/30) 4, 10
• Emphasize the importance of regular physical activity while monitoring for potential exercise-induced hypoglycemia 9