Should You Change or Continue Current Diabetes Medications?
Continue the current regimen of Trijardy XR 25-5-1000 mg daily and Lantus 15 units at night, but intensify therapy by increasing the Lantus dose to achieve better glycemic control. 1
Current Status Assessment
Your patient has made substantial progress, with A1c dropping from 14% to 8.5% over 3 months—a reduction of 5.5 percentage points. 2 However, the current A1c of 8.5% remains above the recommended target of <7% for most adults with type 2 diabetes. 2, 3 The fructosamine level of 324 confirms suboptimal glycemic control over the past 2-3 weeks. 2
Why Continue Current Medications
Trijardy XR is working effectively: The combination of empagliflozin 25 mg, linagliptin 5 mg, and metformin 1000 mg has demonstrated superior glycemic control compared to individual components, with studies showing HbA1c reductions of 1.08-1.19% when used together. 4, 5
The regimen is well-tolerated: Your patient has completed 3 months without apparent adverse effects, and this combination has a low risk of hypoglycemia and favorable weight effects. 6, 7
Switching medications now would be premature: The dramatic improvement from A1c 14% to 8.5% indicates the current medications are addressing the underlying pathophysiology effectively. 7
Recommended Treatment Intensification
Increase Lantus (insulin glargine) dose systematically:
Increase the basal insulin by approximately 2 units every 3 days until fasting plasma glucose reaches 80-130 mg/dL. 1
The current dose of 15 units is likely insufficient given the A1c of 8.5%. 1
Monitor fasting blood glucose daily during dose titration to guide adjustments. 1
If hypoglycemia occurs (blood glucose <70 mg/dL), reduce the insulin dose by 10-20%. 1, 8
Target Goals and Monitoring
Target A1c: <7% for this 50-year-old patient without mention of limiting comorbidities or hypoglycemia history. 2, 3
Recheck A1c in 3 months (quarterly monitoring is recommended when therapy has changed or goals are not met). 2
Fasting plasma glucose target: 80-130 mg/dL. 1
If Goals Still Not Met After Insulin Optimization
Should the A1c remain >7% after optimizing basal insulin over the next 3 months, consider adding prandial insulin:
Start with one dose of rapid-acting insulin (4 units) with the largest meal or meal with greatest postprandial glucose excursion. 1
Alternatively, consider adding a GLP-1 receptor agonist if the patient is not meeting targets with optimized basal insulin and Trijardy XR. 1
Critical Pitfalls to Avoid
Do not discontinue effective medications prematurely: The current regimen has produced a 5.5 percentage point A1c reduction in just 3 months. 4, 5
Do not accept A1c 8.5% as adequate: While less stringent goals (<8%) may be appropriate for elderly or frail patients with limited life expectancy, this 50-year-old patient should target <7% to prevent microvascular complications. 2, 9
Do not delay insulin intensification: The most common error is failing to titrate basal insulin adequately when oral agents alone are insufficient. 1
Ensure medication adherence: Verify the patient is taking Trijardy XR consistently, as non-adherence could explain suboptimal control. 1