What are the next steps for a patient with an A1c of 9.7, taking 10mg Farxiga (dapagliflozin) and 10mg Jardiance (empagliflozin) and 22 units of insulin (insulin) twice daily, to improve glycemic control?

Critical Medication Error: Duplicate SGLT2 Inhibitor Therapy

This patient is taking two SGLT2 inhibitors simultaneously (Farxiga 10mg AND Jardiance 10mg), which is inappropriate and provides no additional benefit while increasing risks—immediately discontinue one of these agents. 1

Immediate Actions Required

1. Stop Duplicate SGLT2 Inhibitor Therapy

• Discontinue either Farxiga or Jardiance immediately—there is no clinical rationale or evidence supporting dual SGLT2 inhibitor therapy, and this duplication wastes resources while potentially increasing adverse effects like genital mycotic infections, urinary tract infections, and volume depletion 1
• Keep whichever SGLT2 inhibitor the patient tolerates better, or default to empagliflozin (Jardiance) given its robust cardiovascular outcomes data in type 2 diabetes 2

2. Aggressively Titrate Basal Insulin

• Increase insulin by 4 units every 3 days until fasting glucose reaches 80-130 mg/dL, as an A1c of 9.7% with current insulin dosing of only 22 units twice daily (44 units total daily) indicates severe under-dosing 3
• For context, this patient likely requires 0.3-0.5 units/kg/day as total daily insulin dose given the A1c >9%, meaning if they weigh 70kg, they need approximately 21-35 units/day as basal insulin alone, not counting prandial coverage 3, 4
• The current total daily dose of 44 units is inadequate for an A1c of 9.7%—most patients at this A1c level require significantly higher doses 3

3. Add Prandial Insulin Coverage

• Start rapid-acting insulin at 4 units before the largest meal (or 10% of basal dose, approximately 4-5 units), as basal insulin alone is insufficient when A1c remains >9% 3, 4
• Blood glucose levels with A1c 9.7% reflect both inadequate basal coverage AND postprandial excursions requiring mealtime insulin 3
• Titrate prandial insulin by 1-2 units or 10-15% twice weekly based on 2-hour postprandial glucose readings 3, 4

4. Add or Optimize GLP-1 Receptor Agonist

• Strongly consider adding a GLP-1 receptor agonist (semaglutide, dulaglutide, or tirzepatide) to the regimen, as the combination of basal insulin + GLP-1 RA provides potent glucose-lowering (1-2% A1c reduction) with weight loss benefits and reduced hypoglycemia risk compared to intensified insulin alone 2, 5
• GLP-1 receptor agonists have established cardiovascular and renal benefits that are independent of A1c lowering, making them particularly valuable in patients with type 2 diabetes at high cardiorenal risk 2

Foundation Therapy Verification

Ensure Metformin is Optimized

• Verify the patient is on metformin at 2000mg daily (or maximum tolerated dose) unless contraindicated, as metformin remains the foundation of type 2 diabetes therapy and should be continued when adding or intensifying insulin 3, 5
• Metformin reduces total insulin requirements and provides complementary glucose-lowering effects 3

Critical Threshold Considerations

When to Stop Escalating Basal Insulin

• When basal insulin exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, prioritize adding or intensifying prandial insulin rather than continuing to escalate basal insulin alone, as further basal increases lead to "overbasalization" with increased hypoglycemia risk and suboptimal control 3, 4
• Clinical signals of overbasalization include: basal dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia episodes, and high glucose variability 3

Monitoring Requirements

Essential Follow-Up

• Daily fasting blood glucose monitoring is essential during insulin titration 3
• Check A1c every 3 months during intensive treatment adjustments 3
• Assess for hypoglycemia at every visit and reduce insulin dose by 10-20% immediately if hypoglycemia occurs without clear cause 3

Common Pitfalls to Avoid

Do Not Delay Insulin Intensification

• Prolonged exposure to A1c >9% (many months) should be specifically avoided, as this increases long-term complication risk and represents therapeutic inertia 2, 4
• Insulin is the most effective glucose-lowering agent when A1c is very high (≥9.0%), and at 9.7%, non-insulin agents alone will not achieve adequate control 4

Do Not Rely on Sliding Scale Insulin Alone

• Sliding scale insulin as monotherapy is explicitly condemned by all major diabetes guidelines and shown to be ineffective—it treats hyperglycemia reactively rather than preventing it 3
• Scheduled basal-bolus regimens are superior to sliding scale monotherapy 3

Do Not Continue Duplicate SGLT2 Inhibitors

• There is no evidence supporting the use of two SGLT2 inhibitors simultaneously, and this practice wastes resources while potentially increasing adverse effects 1

Expected Outcomes

With Proper Intensification

• A1c reduction of 2-3% is achievable with appropriate basal-bolus insulin therapy at weight-based dosing, bringing this patient from 9.7% to approximately 7-7.5% 3
• Addition of GLP-1 RA can provide an additional 1-2% A1c reduction with weight loss benefits 5
• With optimized therapy (corrected SGLT2 inhibitor duplication, intensified insulin, added GLP-1 RA), expect A1c to reach 6.5-7.5% within 3-6 months 5