Insulin Dose Adjustment When Increasing Jardiance to 10 mg
Yes, you should reduce both Lantus (basal insulin) and insulin-to-carbohydrate ratios when increasing Jardiance to 10 mg to prevent hypoglycemia, as SGLT2 inhibitors significantly increase hypoglycemia risk when combined with insulin. 1
Rationale for Dose Reduction
The FDA label for empagliflozin explicitly states that "the risk of hypoglycemia is increased when JARDIANCE is used in combination with insulin" and recommends "a lower dose of insulin may be required to reduce the risk of hypoglycemia when used in combination with JARDIANCE." 1 This is not optional guidance—it is a direct warning about increased hypoglycemia risk that requires proactive insulin adjustment.
Clinical trial data from the EASE program in type 1 diabetes demonstrated that empagliflozin 10 mg reduced total daily insulin requirements by 13.3% while maintaining glycemic control. 2 While this study was in type 1 diabetes, the principle of reduced insulin needs applies equally to insulin-requiring type 2 diabetes patients.
Specific Adjustment Algorithm
Basal Insulin (Lantus) Reduction:
- Reduce Lantus dose by 10-20% immediately when increasing Jardiance to 10 mg 1, 2
- Monitor fasting blood glucose closely for the first 1-2 weeks 3
- Titrate Lantus based on fasting glucose targets (<100 mg/dL or <5.5 mmol/L) 3
- Expect total insulin requirements to decrease by approximately 10-15% over time 2
Insulin-to-Carbohydrate Ratio Adjustment:
- Reduce bolus insulin doses by 10-20% initially to account for improved glucose control from empagliflozin 1
- For patients on carbohydrate counting, this means adjusting the ratio (e.g., from 1:10 to 1:12) 4
- Monitor postprandial glucose levels closely and adjust ratios based on response 4
Critical Monitoring Requirements
Hypoglycemia Prevention:
- Treat hypoglycemia (glucose ≤70 mg/dL) with 15-20g of fast-acting carbohydrates, preferably pure glucose 4, 5, 6
- Recheck blood glucose after 15 minutes and repeat treatment if needed 4, 5
- Once normalized, consume a meal or snack to prevent recurrence 4, 5
- Carbohydrate sources high in protein should be avoided for treating hypoglycemia as they increase insulin response without adequately raising glucose 4, 6
Ketoacidosis Risk:
- Monitor for ketoacidosis symptoms, particularly during acute illness, fasting, or reduced carbohydrate intake 1, 7
- Consider temporarily discontinuing Jardiance during prolonged fasting or acute illness 1
- The risk of euglycemic diabetic ketoacidosis is real with SGLT2 inhibitors, even when blood glucose appears normal 7
Common Pitfalls to Avoid
- Failing to reduce insulin doses proactively leads to increased hypoglycemia risk, which is the most common adverse effect when combining these medications 1, 8
- Not monitoring frequently enough during the first 2-4 weeks after dose adjustment can result in unrecognized hypoglycemia patterns 3
- Treating hypoglycemia with high-protein foods (like peanut butter or cheese) without adequate glucose content can worsen the situation 4, 6
- Continuing usual insulin doses during acute illness or fasting while on Jardiance increases ketoacidosis risk 1, 7
- Not educating patients to carry fast-acting glucose sources at all times increases severe hypoglycemia risk 6
Ongoing Management
- Consistent carbohydrate intake timing and amounts help prevent hypoglycemia when on fixed insulin regimens 4
- For patients on flexible insulin regimens, continue carbohydrate counting but with adjusted ratios 4
- Consider continuous glucose monitoring for patients with recurrent hypoglycemia 6
- Reevaluate and adjust insulin doses every 1-2 weeks based on glucose patterns 3