How to manage a patient with type 2 diabetes and increasing HbA1C on Lantus (insulin glargine), Tradjenta (linagliptin), and Jardiance (empagliflozin)?

Management of Worsening Glycemic Control on Current Triple Therapy

This patient requires immediate and aggressive insulin intensification—increase Lantus by 10-20% every 3 days until fasting glucose reaches 80-130 mg/dL, and strongly consider adding prandial insulin or a GLP-1 receptor agonist, as basal insulin alone will be insufficient to achieve target HbA1c from this level of deterioration. 1

Critical Initial Assessment

Before intensifying therapy, verify medication adherence and check for intercurrent illness, as a 0.4 percentage point rise in HbA1c warrants investigation for non-adherence or acute medical issues 1. Additionally, check renal function immediately—Jardiance has eGFR restrictions and metformin (if she's on it) requires dose adjustment if eGFR is 30-45 mL/min/1.73m² 1.

Primary Recommendation: Aggressive Basal Insulin Titration

• Increase Lantus by 10-20% every 3 days until fasting glucose consistently reaches 80-130 mg/dL 1. At her current dose of 10 units BID (20 units total daily), this means increasing by 2-4 units every 3 days.

• The current Lantus dosing of 10 units BID is suboptimal—she likely needs consolidation to once-daily dosing or significantly higher doses. Patients with type 2 diabetes often require approximately 1 unit/kg to overcome insulin resistance 2, which would suggest she may ultimately need 120 units daily (265 lb ≈ 120 kg).

• Do not delay insulin intensification—an HbA1c of 7.8% with worsening control represents a critical window requiring immediate action 1.

Add Prandial Coverage or GLP-1 Agonist

Basal insulin alone will likely be insufficient to bring HbA1c from 7.8% to target 1. You have two evidence-based options:

Option 1: Add Prandial Insulin (More Aggressive)

• Initiate rapid-acting insulin at 4 units or 10% of basal dose before the largest meal 1
• Expand to other meals as needed based on post-prandial glucose monitoring 2
• This approach provides greater HbA1c reduction (potentially 2.0-2.5%) but causes weight gain 1

Option 2: Add GLP-1 Receptor Agonist (Preferred for Weight Management)

• Adding a GLP-1 agonist instead of prandial insulin provides 1.0-1.5% HbA1c reduction with weight loss rather than weight gain 1
• This is particularly advantageous given her weight of 265 lb 1
• GLP-1 agonists augment glucose-dependent insulin secretion and suppress glucagon, complementing her current regimen 2

Medication Optimization

Continue Jardiance (Empagliflozin)

• Maintain Jardiance, as SGLT2 inhibitors provide additional HbA1c reduction of 0.5-0.7% and promote weight loss, which counteracts insulin-associated weight gain 1
• Jardiance combined with linagliptin (Tradjenta) and insulin has demonstrated efficacy in clinical trials 3, 4
• The combination of empagliflozin and linagliptin produces additive effects at HbA1c values below 8.5% 5

Continue Tradjenta (Linagliptin)

• Linagliptin improves pancreatic islet function by augmenting glucose-dependent insulin secretion and decreasing glucagon 5
• It is weight-neutral with low hypoglycemia risk 5
• Studies demonstrate that adding linagliptin to empagliflozin and metformin reduces HbA1c by an additional 0.32-0.47% 4

Monitoring Requirements

• Increase glucose monitoring frequency immediately—check fasting glucose daily and pre-meal glucose 3-4 times daily during insulin titration to guide dose adjustments and detect hypoglycemia 1
• Recheck HbA1c in 3 months to assess treatment response 1
• Monitor for hypoglycemia, though risk remains low with this regimen compared to intensive insulin therapy in type 1 diabetes 2

Expected Outcomes

• Anticipate HbA1c reduction of 2.0-2.5% with aggressive insulin intensification combined with her current oral agents 1
• Weight gain is expected with insulin intensification, but continuing Jardiance and emphasizing dietary modifications can offset this 1
• Target HbA1c of 7.0% is appropriate for most patients—avoid targeting <6.5% as this increases hypoglycemia risk without cardiovascular benefit 1

Critical Pitfalls to Avoid

• Do not continue gradual titration—HbA1c of 7.8% with worsening control requires immediate aggressive action, not incremental adjustments over months 1
• Do not add pioglitazone or other TZDs—these cause fluid retention, weight gain, increase heart failure risk by 30-40%, and increase fracture risk in women, with risks outweighing benefits when insulin intensification is planned 2, 1
• Do not dismiss the need for prandial coverage—basal insulin optimization alone rarely achieves target HbA1c when starting from 7.8% 1