What adjustments can be made to the current medication regimen for a diabetic patient with an elevated A1C level, who is already on Lantus (insulin glargine), Synjardy (empagliflozin and metformin), and Gliclazide, and for whom GLP-1 analogs are not an option?

Optimize Postprandial Glucose Control to Lower A1C

With a fasting glucose of 5 mmol/L but A1C of 8%, your patient's hyperglycemia is predominantly postprandial, and you should add acarbose 50 mg three times daily with meals to specifically target post-meal glucose excursions. 1

Understanding the Glycemic Pattern

Your patient presents with a critical mismatch:

• Excellent fasting control (5 mmol/L) indicates adequate basal insulin coverage from Lantus 15 units 2
• Elevated A1C of 8% despite good fasting glucose strongly suggests uncontrolled postprandial hyperglycemia 3
• This pattern is common when basal insulin adequately suppresses hepatic glucose output overnight but mealtime glucose excursions remain unaddressed 2

Primary Recommendation: Add Acarbose

Start acarbose 50 mg three times daily with the first bite of each meal, which can reduce A1C by 0.5-0.8 percentage points when added to existing regimens including insulin and sulfonylureas 2. When added to insulin therapy specifically, acarbose reduced A1C by 0.69% and improved one-hour postprandial glucose by 36 mg/dL in clinical trials 1.

Why Acarbose is Optimal Here:

• Targets the specific problem: Reduces postprandial glucose excursions without affecting fasting glucose 2
• No hypoglycemia risk: Does not stimulate insulin secretion, making it safe with your patient's existing sulfonylurea and insulin regimen 2
• Weight neutral: Unlike intensifying insulin, acarbose does not cause weight gain 2
• Complements existing therapy: Works synergistically with metformin (in Synjardy), gliclazide, and basal insulin 1

Practical Implementation:

• Begin with 50 mg at the start of each main meal 1
• Warn the patient about gastrointestinal side effects (flatulence, bloating) which occur in 25-45% of patients but often improve with continued use 2
• Titrate slowly to minimize GI symptoms; can increase to 100 mg three times daily if needed and tolerated (maximum for patients >60 kg) 1
• Reassess A1C in 3 months 2

Alternative Approach: Intensify Insulin Regimen

If acarbose is not tolerated or insufficient after 3 months, add prandial insulin at the largest meal, starting with 4 units of rapid-acting insulin 2, 4.

Prandial Insulin Protocol:

• Start with one injection of rapid-acting insulin (aspart, lispro, or glulisine) before the largest meal 2, 4
• Initial dose: 4 units or 10% of basal insulin dose (1.5 units, round to 2-4 units) 2, 4
• Increase by 1-2 units twice weekly based on 2-hour postprandial glucose readings 2, 4
• Consider reducing gliclazide dose by 50% when adding prandial insulin to reduce hypoglycemia risk, as sulfonylureas combined with complex insulin regimens significantly increase hypoglycemia 4, 5

Why This is Second-Line:

• Increases hypoglycemia risk, especially combined with gliclazide 2
• Causes weight gain of approximately 2 kg 2
• Requires more frequent glucose monitoring and injection burden 2
• More complex regimen may reduce adherence 2

Critical Action: Check Postprandial Glucose

Immediately begin checking 2-hour postprandial glucose levels to quantify the problem and guide treatment adjustments 2, 3. Target postprandial glucose <10 mmol/L (180 mg/dL) 2.

What NOT to Do

• Do not increase Lantus further: Fasting glucose is already at target; increasing basal insulin will cause nocturnal hypoglycemia without addressing postprandial hyperglycemia 2, 4
• Do not increase gliclazide: Already at near-maximum dose (90 mg of 120 mg maximum), and further increases provide minimal additional benefit with increased hypoglycemia risk 2
• Do not add another sulfonylurea or glinide: Would duplicate mechanism of action with gliclazide 2

Monitoring and Follow-Up

• Check A1C every 3 months to assess treatment effectiveness 2, 6
• Monitor for hypoglycemia, particularly if intensifying therapy 2, 4
• Reassess and modify the regimen every 3-6 months to avoid therapeutic inertia 2
• If A1C remains >7% after optimizing postprandial control, consider transitioning to a basal-bolus insulin regimen with dose reduction or discontinuation of gliclazide 2, 4