What is the best regimen for an elderly female patient with hyperglycemia (A1C 9.0) on Novolin 70/30 (NPH insulin/regular insulin) 35 units AM and 30 units PM and Jardiance (empagliflozin) 10mg daily with impaired renal function (GFR 31)?

Optimal Management Strategy for Elderly Patient with Uncontrolled Diabetes and Renal Impairment

This patient requires immediate discontinuation of Jardiance (empagliflozin) due to GFR 31 mL/min/1.73 m², which is below the FDA-mandated threshold of 45 mL/min/1.73 m² for continuation, and intensification of insulin therapy to address the severely uncontrolled A1C of 9.0%. 1

Immediate Actions Required

1. Discontinue Jardiance

• Empagliflozin must be stopped immediately as the FDA label explicitly states: "Discontinue JARDIANCE if eGFR falls persistently below 45 mL/min/1.73 m²" 1
• The current GFR of 31 mL/min/1.73 m² is well below this safety threshold 1
• SGLT2 inhibitors are not expected to be effective at this level of renal function and carry increased risks of volume depletion and urinary tract infections 1

2. Simplify and Intensify Insulin Regimen

Convert from premixed insulin 70/30 to basal insulin only to reduce complexity and hypoglycemia risk while improving glycemic control 2

Recommended Transition:

• Switch to once-daily basal insulin (glargine U-100, U-300, detemir, or degludec) 2
• Starting dose: Calculate total daily dose from current regimen (35 + 30 = 65 units), then reduce by 20-30% when converting from premixed to basal-only = approximately 45-50 units once daily 2
• Administer at bedtime for consistency 3

Rationale for Simplification:

• Premixed insulin 70/30 is complex, requiring precise meal timing and increasing hypoglycemia risk in elderly patients 2
• The American Diabetes Association algorithm for older adults specifically recommends simplifying from premixed to basal insulin when patients have difficulty managing complex regimens 2
• Basal-only insulin has been shown to reduce hypoglycemia and disease-related distress without worsening glycemic control in older adults 2

Glycemic Target Setting

Target A1C <8.0% for this patient based on her complex/intermediate health status (multiple comorbidities including CKD stage 3b) 2

• The 2023-2025 American Diabetes Association guidelines classify patients with multiple coexisting chronic illnesses as complex/intermediate health, warranting an A1C target <8.0% 2
• This target balances glycemic control against hypoglycemia risk, which is substantially elevated in elderly patients with renal impairment 2
• Avoid overly aggressive targets (<7.0%) as overtreatment increases risks of hypoglycemia, falls, and fractures without additional benefit in this population 2, 4

Titration Protocol

Insulin Adjustment:

• Increase basal insulin by 2-4 units every 3 days based on fasting blood glucose 3
• Target fasting glucose: 100-130 mg/dL 3
• Check fasting blood glucose daily during titration 3

Monitoring Schedule:

• Recheck A1C in 3 months 3, 4
• Monitor renal function (GFR, creatinine) every 3-6 months given CKD stage 3b 4
• Assess for hypoglycemia symptoms at each visit 2

Critical Safety Considerations

Hypoglycemia Prevention:

• Elderly patients with renal impairment have markedly increased hypoglycemia risk due to reduced insulin clearance 2
• Educate patient/caregivers on hypoglycemia recognition and treatment 2
• Consider continuous glucose monitoring if available and patient can manage technology 2
• If severe or recurrent hypoglycemia occurs, further simplification or dose reduction is mandatory 2

Renal Function Monitoring:

• With GFR 31, this patient is at high risk for progression to end-stage renal disease 1
• Volume depletion risk increases with worsening renal function 1
• Urinary tract infection risk is elevated in elderly women with diabetes and renal impairment 1

Alternative Considerations if Glycemic Control Inadequate

If A1C remains >8.0% after 3 months of optimized basal insulin:

1. Add metformin 500 mg twice daily if GFR remains ≥30 mL/min/1.73 m² 2

   • Metformin can be used safely with eGFR ≥30 mL/min/1.73 m² 2
   • Start low dose to minimize gastrointestinal side effects 2
   • Must discontinue if GFR falls below 30 2

2. Consider adding mealtime insulin only if patient demonstrates ability to manage increased complexity 2

   • Start with 4-6 units rapid-acting insulin before largest meal 5
   • This increases regimen complexity and should only be done if patient/caregiver can safely manage 2

Common Pitfalls to Avoid

• Do NOT continue empagliflozin despite its renal protective effects in other populations—it is contraindicated at this GFR 1
• Do NOT maintain premixed insulin as it increases hypoglycemia risk and complexity in elderly patients 2
• Do NOT target A1C <7.0% as this constitutes overtreatment in a patient with complex health status 2, 6
• Do NOT add sulfonylureas as they carry high hypoglycemia risk, particularly in renal impairment 2

Expected Outcomes

• With simplified basal insulin regimen, expect A1C reduction of approximately 1.0-1.5% over 3 months 2
• Reduced hypoglycemia episodes compared to premixed insulin 2
• Improved treatment adherence due to simplified once-daily regimen 2
• Maintained quality of life while achieving safer glycemic control 2