For a patient with poorly controlled hyperglycemia, a hemoglobin A1c level of 10.2%, and currently on Trulicity (dulaglutide) 1.5 mg weekly, Jardiance (empagliflozin) 10 mg daily, and sliding scale insulin, do you recommend switching to insulin (insulin therapy) only?

Do Not Switch to Insulin-Only Therapy

For a patient with an HbA1c of 10.2% on Trulicity 1.5 mg weekly, Jardiance 10 mg daily, and sliding scale insulin, you should intensify the current regimen by optimizing basal insulin and adding scheduled prandial insulin while continuing the GLP-1 receptor agonist and SGLT2 inhibitor, rather than switching to insulin alone. 1

Why Insulin-Only is the Wrong Approach

Current Medications Provide Critical Benefits Beyond Glucose Control

• Trulicity (dulaglutide) should be continued because GLP-1 receptor agonists provide cardiovascular and kidney protection benefits that insulin cannot offer, reduce hypoglycemia risk, and promote weight loss rather than weight gain 1

• Jardiance (empagliflozin) should be continued because SGLT2 inhibitors have demonstrated cardiovascular benefits in patients with established atherosclerotic CVD, benefits for heart failure, and slow progression of chronic kidney disease 1

• The combination of basal insulin with GLP-1 receptor agonists provides the most rapid and effective glycemic control with less weight gain and hypoglycemia than intensified insulin-only regimens 1

Evidence Supporting Combination Therapy Over Insulin Alone

• Studies directly comparing GLP-1 receptor agonists with insulin glargine in patients with HbA1c ≥9% show that GLP-1 receptor agonists provide equal or superior HbA1c reduction (up to 3.1% reduction from baseline HbA1c of 10.6%) with the added benefits of weight loss instead of weight gain 2

• Empagliflozin added to basal insulin in patients with inadequately controlled type 2 diabetes reduced HbA1c by 0.6-0.7% at 18 weeks and reduced insulin requirements while promoting weight loss 3

The Correct Treatment Intensification Strategy

Step 1: Eliminate Sliding Scale Insulin Immediately

• Sliding scale insulin as monotherapy or primary therapy is explicitly condemned by all major diabetes guidelines and should be immediately discontinued 1, 4

• Sliding scale insulin treats hyperglycemia reactively after it occurs rather than preventing it, leading to dangerous glucose fluctuations 1, 4

Step 2: Initiate Proper Basal-Bolus Insulin Regimen

For an HbA1c of 10.2%, you need immediate basal-bolus therapy, not basal insulin alone 1, 4

Calculate Total Daily Insulin Dose

• Start with 0.3-0.5 units/kg/day as total daily insulin dose given the HbA1c >10% 1, 4

• Divide as 50% basal insulin (long-acting insulin glargine or detemir once daily) and 50% prandial insulin (rapid-acting insulin divided among three meals) 1, 4

Basal Insulin Titration

• If not already on adequate basal insulin, start with 10 units once daily or 0.1-0.2 units/kg/day 1, 5

• Increase by 4 units every 3 days if fasting glucose ≥180 mg/dL until fasting glucose reaches 80-130 mg/dL 1, 4

• Increase by 2 units every 3 days if fasting glucose is 140-179 mg/dL 1, 4

Prandial Insulin Initiation

• Start with 4 units of rapid-acting insulin before the largest meal or use 10% of the basal insulin dose 1, 4

• Increase prandial insulin by 1-2 units or 10-15% twice weekly based on 2-hour postprandial glucose readings 1, 4

• Add prandial insulin before additional meals sequentially if HbA1c remains elevated 4

Step 3: Optimize Jardiance Dosing

• Increase Jardiance from 10 mg to 25 mg daily if not contraindicated, as the higher dose provides greater HbA1c reduction and cardiovascular benefits 6, 3

Step 4: Continue Trulicity at Current Dose

• Maintain Trulicity 1.5 mg weekly as this provides the highest weight loss efficacy among GLP-1 receptor agonists and superior HbA1c reduction compared to insulin alone 7, 2

Expected Outcomes with Proper Intensification

• HbA1c reduction of 2-3% is achievable from current levels with appropriate basal-bolus therapy at weight-based dosing 4

• 68% of patients achieve mean blood glucose <140 mg/dL with proper basal-bolus regimens versus only 38% with sliding scale alone 4

• The combination approach provides superior glycemic control with reduced total insulin requirements compared to insulin-only therapy 1

Critical Pitfalls to Avoid

• Never delay insulin intensification for months while trying additional oral agents alone, as this prolongs exposure to severe hyperglycemia and increases complication risk 1, 4

• Never discontinue Trulicity or Jardiance when adding insulin, as these agents provide complementary mechanisms and reduce total insulin requirements 1

• Never rely solely on sliding scale insulin without optimizing basal insulin first, as this is ineffective for long-term management 1, 4

• Never continue escalating basal insulin beyond 0.5-1.0 units/kg/day without adding prandial coverage, as this causes overbasalization with hypoglycemia and suboptimal control 1, 4

Monitoring Requirements

• Daily fasting blood glucose monitoring is essential during titration 1, 4

• Check pre-meal and 2-hour postprandial glucose to guide prandial insulin adjustments 4

• Reassess HbA1c every 3 months during intensive titration 4

• Monitor for hypoglycemia and provide comprehensive patient education on recognition and treatment 1, 4