Can an 81-year-old male with type 2 diabetes, body mass index (BMI) of 26, and elevated blood glucose levels, who is currently on Lantus (insulin glargine) 28 units, safely restart Jardiance (empagliflozin) 10 mg and sitagliptin, and if so, should his Lantus dose be adjusted?

Restarting Jardiance and Sitagliptin at Discharge

Yes, restart both Jardiance 10 mg and sitagliptin at discharge, and reduce the Lantus dose by approximately 20% (from 28 units to 22 units) when initiating these medications. 1

Rationale for Medication Restart

SGLT2 Inhibitor (Jardiance)

• Jardiance is appropriate for this patient given his age, BMI, and current glycemic control status 1
• The 2024 ADA guidelines support SGLT2 inhibitor use in older adults with type 2 diabetes, with no specific upper age limit contraindication 1
• Key safety consideration: Ensure eGFR is ≥20 mL/min/1.73 m² before restarting, as this is the current threshold for SGLT2 inhibitor use 1
• Jardiance can be safely combined with insulin and DPP-4 inhibitors like sitagliptin 2, 3

DPP-4 Inhibitor (Sitagliptin)

• Sitagliptin is well-suited for elderly patients as it has a low hypoglycemia risk when used without insulin secretagogues 1, 4
• Recent evidence demonstrates that sitagliptin combined with basal insulin is safe and effective in hospitalized patients, making it appropriate for discharge 1
• Dose adjustment required: Use 50 mg daily if eGFR 30-50 mL/min/1.73 m², or 25 mg daily if eGFR <30 mL/min/1.73 m² 4

Insulin Dose Adjustment Protocol

Immediate Lantus Reduction

• Reduce Lantus from 28 units to 22 units (approximately 20% reduction) when starting both medications 1
• This reduction prevents hypoglycemia risk when adding glucose-lowering agents to existing insulin therapy 1
• The 20% reduction is specifically recommended by the American College of Cardiology when initiating SGLT2 inhibitors or GLP-1 RAs in patients with well-controlled HbA1c or history of hypoglycemia 1

Titration Strategy After Discharge

• Monitor fasting blood glucose for 1-2 weeks after discharge 1
• Titration goal: Fasting glucose 90-150 mg/dL (5.0-8.3 mmol/L) 1
• If ≥50% of fasting readings exceed goal over one week: Increase Lantus by 2 units 1
• If >2 fasting readings per week are <80 mg/dL (<4.4 mmol/L): Decrease Lantus by 2 units 1

Critical Safety Monitoring

First 4 Weeks Post-Discharge

• Instruct patient to monitor blood glucose 3-4 times daily during the initial period 1
• This intensive monitoring is essential when combining SGLT2 inhibitors with insulin 1

SGLT2 Inhibitor-Specific Education

• Educate about euglycemic ketoacidosis: Can occur even with blood glucose 150-250 mg/dL 1, 5
• Warning symptoms: nausea, vomiting, abdominal pain, weakness, trouble breathing 5
• Genital hygiene importance: Risk of mycotic infections 3-5.5% 1, 3
• Volume depletion precautions: Hold medication if unable to maintain oral intake, vomiting, or diarrhea 1, 5
• Foot care vigilance: Especially important in elderly patients with potential neuropathy 1

Hypoglycemia Risk Management

• Low risk with this combination as neither sitagliptin nor Jardiance independently cause hypoglycemia 4, 6
• The primary hypoglycemia risk comes from the basal insulin, which is why the 20% reduction is critical 1
• Ensure patient has fast-acting glucose available and understands hypoglycemia symptoms 5

Common Pitfalls to Avoid

Do Not Continue Insulin at Full Dose

• Failure to reduce insulin when adding SGLT2 inhibitors increases hypoglycemia risk significantly 1
• The 20% reduction is not optional—it is a guideline-recommended safety measure 1

Avoid Premature Discontinuation

• Do not stop sitagliptin if patient experiences mild gastrointestinal symptoms (occurs in up to 16% but usually resolves) 4
• These are typically transient and do not require medication discontinuation 4

Renal Function Monitoring

• Check renal function before discharge to ensure appropriate dosing of both medications 1, 4
• Jardiance requires eGFR ≥20 mL/min/1.73 m² 1
• Sitagliptin requires dose reduction with eGFR <50 mL/min/1.73 m² 4

Discharge Instructions Summary

Medication regimen:

• Lantus 22 units daily (reduced from 28 units)
• Jardiance 10 mg once daily
• Sitagliptin 100 mg once daily (adjust for renal function if needed)

Monitoring: Check fasting blood glucose daily for 2 weeks, then adjust Lantus as outlined above 1

Follow-up: Schedule outpatient visit within 2-4 weeks to assess glycemic control and medication tolerance 1