What medication dose should be increased in a patient with HbA1c 8.5% on Soligua (insulin glargine) 30 units, Lyumjev (insulin lispro-aabc) 12 units TID, and Jardiance (empagliflozin) 10 mg to improve glycemic control?

Increase Jardiance to 25 mg Daily

For a patient with HbA1c 8.5% on Soligua 30 units, Lyumjev 12 units TID, and Jardiance 10 mg, the most appropriate medication to increase is Jardiance from 10 mg to 25 mg daily. 1

Rationale for Jardiance Dose Escalation

The FDA label for Jardiance explicitly states that "in patients tolerating JARDIANCE, the dose may be increased to 25 mg" once daily 1. This patient is already on substantial insulin therapy (both basal and prandial components), making further insulin intensification less desirable due to increased hypoglycemia risk and weight gain 2, 3.

Jardiance dose escalation offers several advantages:

• Cardiovascular and renal protection beyond glycemic control, particularly important given established cardiovascular benefits of SGLT2 inhibitors 3
• Weight loss rather than weight gain, contrasting with insulin intensification 4
• Lower hypoglycemia risk compared to increasing insulin doses 3, 4
• Complementary mechanism of action to existing insulin therapy, providing insulin-independent glucose lowering 2

Why Not Increase Insulin Components

Soligua (Basal Insulin Component)

The patient is receiving 30 units of Soligua, which contains insulin glargine. When basal insulin exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, adding adjunctive therapy becomes more appropriate than continuing to escalate basal insulin alone 2, 5. Further basal insulin escalation risks "overbasalization" with clinical signals including hypoglycemia and high glucose variability 2, 5.

Lyumjev (Prandial Insulin)

The patient is already receiving 12 units TID (36 units total daily) of prandial insulin. Before intensifying prandial insulin further, optimizing non-insulin agents is preferred 2, 3. The total insulin burden (30 units basal + 36 units prandial = 66 units daily) suggests the patient would benefit more from adjunctive therapy than additional insulin 2.

Implementation Strategy

Increase Jardiance from 10 mg to 25 mg once daily in the morning, taken with or without food 1. This dose escalation is straightforward and requires no complex titration algorithm.

Critical Monitoring Requirements

• Assess renal function before dose escalation; Jardiance should not be used if eGFR is persistently below 45 mL/min/1.73 m² 1
• Monitor for volume depletion and hypotension, particularly if the patient is elderly or on diuretics 1
• Educate about ketoacidosis symptoms (nausea, vomiting, abdominal pain, dyspnea) and instruct to check ketones if these occur, even with blood glucose <250 mg/dL 1
• Reassess HbA1c in 3 months to determine if additional intensification is needed 3

Expected Outcomes

With Jardiance dose escalation from 10 mg to 25 mg, expect an additional HbA1c reduction of approximately 0.3-0.5% 2, 3. This should bring the patient closer to the target HbA1c of <7% for most adults with type 2 diabetes 2, 3.

Common Pitfalls to Avoid

• Do not discontinue metformin if the patient is taking it; metformin should remain the foundation of therapy unless contraindicated 2, 3, 6
• Do not delay Jardiance dose escalation waiting for insulin adjustments alone, as the combination approach provides superior outcomes 3
• Do not ignore renal function monitoring; SGLT2 inhibitors require periodic assessment of kidney function 1
• Avoid continuing to escalate insulin doses beyond 0.5-1.0 units/kg/day without addressing the need for adjunctive non-insulin therapy 2, 5