What adjustments should be made to a diabetes management plan for a patient with significant hyperglycemia who is already taking Jardiance (empagliflozin)?

Management of A1C 10% in a Patient on Jardiance

For a patient with A1C of 10% already taking Jardiance (empagliflozin), insulin therapy should be initiated immediately, as this level of severe hyperglycemia requires the most potent glucose-lowering intervention available. 1

Rationale for Insulin Initiation

When A1C exceeds 10%, current guidelines uniformly recommend insulin as the treatment of choice, regardless of existing oral medications. 1 This threshold represents severe hyperglycemia with likely glucose toxicity, where:

• Blood glucose levels are typically ≥300 mg/dL consistently 1
• Beta-cell function is significantly impaired by glucotoxicity 1
• Patients may have catabolic features (weight loss, ketonuria) requiring urgent intervention 1
• Insulin provides the most rapid and reliable glucose reduction 1

The 2025 ADA Standards of Care explicitly state that insulin should be considered when A1C >10% or blood glucose ≥300 mg/dL, even in patients already on other medications. 1

Specific Insulin Regimen

Start basal insulin at 10 units daily or 0.1-0.2 units/kg/day: 2

• Titrate by increasing 2 units every 3 days until fasting glucose reaches target (80-130 mg/dL) 2
• Maximum basal dose should not exceed approximately 0.5 units/kg/day to avoid overbasalization 2
• Continue Jardiance during insulin initiation, as SGLT2 inhibitors provide complementary mechanisms and cardiovascular benefits 1, 3

If fasting glucose improves but A1C remains elevated, add prandial insulin: 2

• Start with 4 units before the largest meal or 10% of basal insulin dose 2
• Titrate by 1-2 units or 10-15% twice weekly based on post-prandial readings 2

Metformin Optimization

Ensure metformin is maximized (if not already on it) or add it if contraindications are absent (eGFR ≥30 mL/min/1.73 m²): 1, 2

• Metformin combined with insulin limits weight gain and provides additional A1C reduction of 0.5-0.8% 1
• The combination of insulin + metformin + SGLT2 inhibitor addresses multiple pathophysiologic defects 1, 2

Additional Considerations

Consider adding a GLP-1 receptor agonist once glucose toxicity resolves: 1, 2

• GLP-1 RAs can provide 0.6-0.8% additional A1C reduction 2
• They offer weight loss benefits (counteracting insulin-associated weight gain) 1
• Evidence supports their use even in patients with baseline A1C of 10-12%, though data are limited 1

Monitor for hypoglycemia risk, especially as glucose improves: 2

• If hypoglycemia occurs, reduce the corresponding insulin dose by 10-20% 2
• SGLT2 inhibitors like Jardiance do not increase hypoglycemia risk when combined with insulin 4

Transition Strategy After Glucose Control

Once A1C improves to <8% and glucose toxicity resolves (typically 2-3 months), consider simplifying the regimen: 1

• Insulin doses may be reduced or potentially discontinued if oral agents can maintain control 1
• Continue Jardiance for its cardiovascular and renal protective effects, independent of glucose lowering 1, 3
• The EMPA-REG OUTCOME trial demonstrated 38% reduction in cardiovascular death with empagliflozin 3

Common Pitfalls to Avoid

Do not delay insulin initiation while attempting to optimize oral agents at this A1C level: 1

• At A1C 10%, oral agents alone (including SGLT2 inhibitors) are insufficient to achieve timely glucose control 1
• Prolonged severe hyperglycemia increases risk of microvascular complications and worsens beta-cell function 1

Do not discontinue Jardiance when starting insulin: 1, 2

• SGLT2 inhibitors provide complementary glucose lowering through renal mechanisms 4
• Cardiovascular and renal benefits persist independent of glucose effects 1, 3
• The combination is safe and well-tolerated, with no increased hypoglycemia risk 4

Do not use sulfonylureas as an alternative to insulin at this A1C level: 1

• While some evidence suggests sulfonylureas or GLP-1 RAs can treat severe hyperglycemia, data are scarce for A1C >10% 1
• Insulin remains the most reliable and rapid intervention 1