What adjustments should be made to a Diabetes Mellitus Type 2 patient's regimen of glargine (insulin glargine) and dapagliflozin to achieve adequate glycemic control?

Insulin Regimen Adjustment for Inadequate Glycemic Control

Immediate Insulin Dose Escalation Required

The glargine dose must be increased substantially from 10 units to at least 20-25 units once daily, as the current dose is grossly inadequate for a patient with blood glucose of 310 mg/dL. 1, 2

The current regimen demonstrates a critical mismatch between insulin requirements and dosing. A blood glucose of 310 mg/dL indicates severe insulin deficiency that cannot be addressed with the current 10-unit dose. 2

Specific Titration Protocol

Basal Insulin (Glargine) Adjustment

• Increase glargine immediately to 20-25 units once daily administered at the same time each evening 2
• Titrate upward by 2-4 units every 3-4 days until fasting blood glucose consistently reaches 100-130 mg/dL 1, 2, 3
• Continue titration aggressively—patients with type 2 diabetes typically require 0.3-0.5 units/kg/day of basal insulin, far exceeding the current 10 units 2
• The basal insulin should constitute approximately 50% of total daily insulin requirements 4, 2

Sliding Scale Insulin (SSI) Discontinuation

Discontinue the sliding scale insulin regimen entirely and convert to scheduled basal-bolus therapy with fixed prandial doses. 4, 1

SSI is inferior to basal-bolus regimens for glycemic control and is associated with higher treatment failure rates (19% vs 0-2% with basal-bolus or basal-plus regimens). 4 Multiple randomized trials demonstrate that basal-bolus regimens achieve superior glycemic control compared to SSI, with one study showing treatment failure in 14 of 74 patients (19%) on SSI versus 0 of 144 patients on basal-bolus. 4

Prandial Insulin Implementation

• Add scheduled rapid-acting insulin (e.g., lispro, aspart, or glulisine) before meals starting with 4 units per meal or 10% of the basal insulin dose 1
• Administer 15 minutes before each meal for optimal postprandial glucose control 1
• Increase prandial doses by 1-2 units or 10-15% every 3-7 days based on postprandial glucose readings 1
• Distribute mealtime insulin across three meals: typically 30-40% at breakfast, 30-40% at lunch, and 30-40% at dinner 2

SGLT2 Inhibitor Continuation

Continue dapagliflozin 10 mg daily without interruption. 5, 6

The switch from Jardiance (empagliflozin) to dapagliflozin is appropriate and both agents are equivalent in this context. 5 Dapagliflozin provides:

• Additional glucose-lowering effect (HbA1c reduction of 0.54-0.89%) 7
• Weight reduction of 2-3 kg 7, 6
• Blood pressure reduction (systolic 2-5 mmHg) 7
• Cardiovascular and renal protective benefits independent of glucose control 4, 6

When combined with insulin, dapagliflozin stabilizes insulin dosing requirements and mitigates insulin-associated weight gain over 48-104 weeks. 8, 9

Critical Monitoring Parameters

Blood Glucose Monitoring Strategy

• Check fasting glucose daily during insulin titration to guide basal insulin adjustments 1, 2, 10
• Check pre-meal glucose before each meal to assess overall control 1
• Check 2-hour postprandial glucose after the largest meal to guide prandial insulin adjustments 1
• Increase monitoring frequency during dose adjustments to detect hypoglycemia early 1

Target Glucose Ranges

• Fasting plasma glucose: 80-130 mg/dL (4.4-7.2 mmol/L) 1, 2
• Postprandial glucose: <180 mg/dL (10.0 mmol/L) 1
• Random blood glucose: <180 mg/dL (10.0 mmol/L) 4

Metformin Optimization

Add or optimize metformin to 1000 mg twice daily (2000 mg total) if not already prescribed or if currently on suboptimal doses. 4, 1, 10

Metformin is the preferred first-line agent and should be continued when used in combination with insulin therapy. 4, 1 The combination of basal insulin plus metformin is particularly effective for lowering glycemia while limiting weight gain. 1

Common Pitfalls to Avoid

Insulin Dose Inadequacy

The most critical error in this case is under-dosing basal insulin. A 10-unit dose is insufficient for virtually any adult with type 2 diabetes showing blood glucose of 310 mg/dL. 2 The typical starting dose for insulin-naive patients is 0.2 units/kg or up to 10 units, but this patient clearly requires immediate escalation beyond starting doses. 3

Continued Reliance on SSI

Do not continue SSI as the primary insulin strategy. 4 SSI results in reactive rather than proactive glucose management and is associated with significantly higher rates of treatment failure and complications. 4

Delayed Intensification

Do not delay insulin intensification when oral agents and low-dose insulin fail to achieve glycemic targets. 1 The progressive nature of type 2 diabetes requires timely escalation of therapy. 4

Hypoglycemia Risk Management

• Reduce insulin dose by 10-20% if hypoglycemia occurs 1
• Ensure patient carries 15-20 grams of fast-acting carbohydrate at all times 1
• Prescribe glucagon for emergency use and educate family members on administration 1

SGLT2 Inhibitor Safety Considerations

Genital and Urinary Tract Infections

Dapagliflozin is associated with higher rates of genital infections (7.4-14.3% vs 3.0% with placebo) and urinary tract infections (8.4-13.8% vs 5.6% with placebo). 9 However, most events:

• Occur in the first 24 weeks of therapy 9
• Are single episodes that respond to routine management 9
• Should not preclude continued use given the cardiovascular and renal benefits 6

Diabetic Ketoacidosis (DKA)

Although rare, DKA risk is elevated with SGLT2 inhibitors. 6 Withhold dapagliflozin for at least 3 days prior to major surgery or procedures associated with prolonged fasting. 5

Follow-Up Timeline

• Week 1: Assess tolerance to increased insulin doses, review glucose logs, adjust basal insulin by 2-4 units if fasting glucose not at target 1, 2, 10
• Weeks 2-4: Continue weekly or biweekly follow-ups with ongoing insulin titration until fasting glucose reaches 100-130 mg/dL 2, 10
• Week 12: Check HbA1c; if above target despite optimized basal insulin, advance to full basal-bolus regimen or consider adding GLP-1 receptor agonist 4, 1
• Ongoing: Check HbA1c every 3 months until target is achieved 1