Management of Type 2 Diabetes with A1C 9.6% on Insulin and Farxiga
Add a GLP-1 receptor agonist immediately to this regimen, as the 2025 ADA Standards of Care explicitly recommend adding GLP-1 RA or dual GIP/GLP-1 RA when A1C remains above goal despite insulin therapy. 1
Immediate Treatment Intensification Required
Your patient's A1C of 9.6% represents poor glycemic control despite being on both insulin and an SGLT2 inhibitor (Farxiga/dapagliflozin), indicating urgent need for treatment intensification rather than continued observation. 1
Primary Recommendation: Add GLP-1 Receptor Agonist
The 2025 ADA guidelines state that if A1C is above goal and the individual is not already on a GLP-1 RA or dual GIP/GLP-1 RA, consider these classes in combination with insulin. 1
GLP-1 RAs provide complementary mechanisms to both insulin and SGLT2 inhibitors, with expected A1C reductions of 1.4-1.8% when added to existing therapy. 2
Consider a fixed-ratio combination product (IDegLira or iGlarLixi) if the patient is on basal insulin, as this simplifies the regimen and improves adherence. 1
Weekly GLP-1 RAs (dulaglutide, semaglutide, exenatide QW) or the dual GIP/GLP-1 RA tirzepatide offer superior A1C reductions (2.1-2.4%) with once-weekly dosing convenience. 3, 4
Optimize Current Insulin Regimen
Before or concurrent with adding GLP-1 RA, assess for signs of "overbasalization" that indicate your basal insulin dose may be excessive without achieving glycemic control: 1
Check if fasting glucose is controlled but A1C remains elevated - this suggests inadequate postprandial coverage rather than insufficient basal insulin. 1
Look for elevated bedtime-to-morning glucose differential or postprandial-to-preprandial glucose excursions. 1
Evaluate for hypoglycemia (aware or unaware) and high glucose variability. 1
If Overbasalization is Present:
Add prandial insulin starting with one dose at the largest meal (typically 4 units or 10% of basal dose), rather than further increasing basal insulin. 1
Titrate prandial insulin by 1-2 units or 10-15% every 3 days based on postprandial glucose readings. 1
If A1C <8% when adding prandial insulin, consider lowering basal dose by 4 units or 10% to prevent hypoglycemia. 1
Verify Farxiga Optimization
Confirm the patient is on dapagliflozin 10 mg daily, as this is the maximum effective dose for glycemic control. 5
Dapagliflozin provides A1C reductions of 0.6-0.8% when added to insulin, with additional benefits of weight loss (1-4 kg) and blood pressure reduction. 6, 7, 8
In patients with baseline A1C ≥9%, dapagliflozin reduces A1C by approximately 1.4% over 24 weeks. 7
Critical Monitoring and Follow-Up
Reassess A1C in 3 months after treatment intensification - this is the standard timeframe to evaluate effectiveness of therapy changes. 2
Monitor for hypoglycemia, especially when combining insulin with GLP-1 RA, though risk is substantially lower than with insulin alone. 3
Check renal function before and after adding GLP-1 RA, as these agents are renally cleared. 3
Assess for genital infections and urinary tract infections with continued SGLT2 inhibitor use, though most occur early in treatment. 6
Common Pitfalls to Avoid
Do not continue to uptitrate basal insulin alone when A1C remains elevated despite adequate fasting glucose control - this leads to overbasalization with increased hypoglycemia risk and weight gain without improving A1C. 1
Do not delay adding GLP-1 RA while waiting to "see if insulin adjustment works" - therapeutic inertia at this A1C level (1.5-2% above typical goals) prolongs exposure to hyperglycemia and increases complication risk. 1, 2
Do not add a DPP-4 inhibitor if you choose a GLP-1 RA, as there is no added glucose-lowering benefit beyond GLP-1 RA alone. 3
Alternative Consideration: Dual GIP/GLP-1 RA
If the patient has significant obesity or cardiovascular risk factors, prioritize tirzepatide (dual GIP/GLP-1 RA) over traditional GLP-1 RAs, as it demonstrates superior A1C reductions of 2.1-2.4% even when added to insulin. 3