What to do for a patient with increasing HbA1C on Lantus (Insulin Glargine) and sliding scale Humalog (Insulin Lispro), Jardiance (Empagliflozin), and Jentadueto (Linagliptin/Metformin)?

Management of Rising HbA1c Despite Intensive Insulin and Oral Therapy

Immediate Action: Aggressive Insulin Titration Required

Your patient's HbA1c increase from 7.5% to 8.0% on Lantus 40 units BID (total 80 units daily), sliding scale Humalog, Jardiance, and Jentadueto represents inadequate basal insulin coverage that requires immediate dose escalation, not medication addition. 1

Critical First Steps

• Verify medication adherence immediately - a 0.5% HbA1c deterioration warrants investigation for non-adherence, intercurrent illness, or insulin storage/injection technique problems before assuming treatment failure 1
• Check renal function urgently - metformin (in Jentadueto) requires dose adjustment if eGFR 30-45 mL/min/1.73m² and discontinuation if eGFR <30 mL/min/1.73m², and empagliflozin (Jardiance) has eGFR restrictions 2, 1
• Assess fasting glucose patterns - if fasting glucose exceeds 130 mg/dL, the basal insulin dose is insufficient regardless of total daily dose 1, 3

Primary Recommendation: Optimize Basal Insulin First

Increase Lantus by 10-20% (8-16 units per injection) every 3 days until fasting glucose reaches 80-130 mg/dL, as premature addition of other agents without optimizing basal coverage increases complexity, cost, and hypoglycemia risk. 1, 3

Basal Insulin Titration Algorithm

• Titrate aggressively - increase each Lantus dose by 4 units every 3 days if fasting glucose >130 mg/dL 1, 3
• Target fasting glucose 80-130 mg/dL - do not accept higher targets as this perpetuates hyperglycemia 1
• Monitor daily fasting glucose during titration to guide dose adjustments and detect hypoglycemia 1
• Continue titration until fasting glucose consistently reaches target or hypoglycemia occurs (glucose <70 mg/dL), at which point reduce dose by 10-20% 3

Expected Basal Insulin Requirements

• Typical total daily basal insulin needs range from 0.5-1.0 units/kg/day for type 2 diabetes 3
• Current dose of 80 units daily may still be subtherapeutic if the patient weighs >80-160 kg or has significant insulin resistance 3
• Do not arbitrarily cap basal insulin doses - continue titration based on glucose response, not predetermined dose limits 1, 3

Secondary Consideration: Add Prandial Insulin Coverage

If basal insulin optimization alone (reaching 0.5 units/kg/day) fails to achieve HbA1c <7.5% after 3 months, add rapid-acting insulin at 4 units or 10% of basal dose before the largest meal, then expand to other meals as needed. 1, 3

Prandial Insulin Implementation

• Start with the largest meal - initiate Humalog 4 units before dinner (typically the largest meal) rather than using sliding scale alone 1
• Titrate prandial doses by 1-2 units every 3 days targeting 2-hour postprandial glucose <180 mg/dL 1
• Expand coverage systematically - add breakfast insulin next, then lunch, based on postprandial glucose patterns 1
• Discontinue sliding scale once scheduled prandial insulin is established, as reactive correction is inferior to proactive dosing 1

Alternative Strategy: Consider GLP-1 Receptor Agonist Instead of Prandial Insulin

Adding a GLP-1 receptor agonist (semaglutide, dulaglutide, or liraglutide) to optimized basal insulin provides 1.0-1.5% HbA1c reduction with weight loss rather than weight gain, and may be preferable to prandial insulin for patients concerned about weight or injection burden. 1, 4, 5

GLP-1 RA Selection and Evidence

• Semaglutide or dulaglutide are preferred weekly options that reduce HbA1c by 1.0-1.5% when added to basal insulin, with superior or equivalent efficacy compared to adding prandial insulin 4, 6, 5
• Exenatide twice daily reduced HbA1c by 1.13% when added to insulin glargine (mean 61 units/day) and metformin, non-inferior to adding thrice-daily prandial lispro (1.10% reduction) 5
• Weight benefit is substantial - GLP-1 RAs cause 2-3 kg weight loss versus 2 kg weight gain with prandial insulin 4, 5
• Hypoglycemia risk is lower - documented symptomatic hypoglycemia occurred in 15.8% with weekly albiglutide versus 29.9% with thrice-daily lispro when added to basal insulin 4

GLP-1 RA Practical Considerations

• Gastrointestinal side effects occur in 11-12% (nausea) and 6-7% (vomiting) but typically diminish over 4-8 weeks 4
• Continue Jardiance when adding GLP-1 RA, as SGLT2 inhibitors provide complementary mechanisms and additional 0.5-0.7% HbA1c reduction 2, 7
• Cost may be prohibitive - GLP-1 RAs cost substantially more than prandial insulin, though improved adherence and reduced hypoglycemia may offset costs 2

Medication Regimen Reassessment

Continue Current Oral Agents

• Maintain Jardiance (empagliflozin) - SGLT2 inhibitors provide cardiovascular and renal benefits independent of glucose lowering, and should be continued unless eGFR falls below threshold 2, 1
• Continue Jentadueto (linagliptin/metformin) - metformin remains foundational therapy and linagliptin adds modest glycemic benefit without hypoglycemia risk 2
• Verify metformin dose - ensure patient receives at least 2000 mg daily if tolerated, as higher doses provide greater efficacy 2

Address Potential Barriers

• Assess for vitamin B12 deficiency - metformin use increases risk of B12 deficiency and worsening neuropathy symptoms; check B12 levels periodically 2
• Review insulin injection technique - improper injection technique, lipohypertrophy, or localized cutaneous amyloidosis can impair insulin absorption 8
• Check insulin storage - insulin exposed to extreme temperatures loses potency 8

Monitoring and Follow-up

Immediate Monitoring Requirements

• Daily fasting glucose during basal insulin titration to guide dose adjustments 1, 3
• Pre-meal glucose 3-4 times daily if adding prandial insulin to guide dose titration 1
• Hypoglycemia awareness education - review symptoms and treatment of glucose <70 mg/dL 1

Expected Outcomes

• HbA1c reduction of 1.0-1.5% is achievable with aggressive insulin optimization, bringing HbA1c from 8.0% to 6.5-7.0% 1, 6
• Recheck HbA1c in 3 months to assess treatment response and determine if further intensification is needed 2, 1
• Weight gain of 2-3 kg is expected with insulin intensification; continuing Jardiance and emphasizing dietary modifications can partially offset this 1, 4

Common Pitfalls to Avoid

• Do not delay insulin intensification - HbA1c of 8.0% on 80 units of basal insulin daily indicates inadequate dosing, not insulin failure 1, 3
• Do not add prandial insulin before optimizing basal insulin - fasting glucose must reach target (80-130 mg/dL) before addressing postprandial excursions 3
• Do not continue sliding scale as sole prandial coverage - scheduled prandial insulin doses are superior to reactive correction 1
• Do not assume 80 units daily is "high dose" - many patients require 100-150 units daily or more to achieve glycemic targets 1, 3
• Do not discontinue SGLT2 inhibitor - Jardiance provides cardiovascular and renal benefits independent of glucose lowering and should be continued 2, 1