Should a provider add Lantus (insulin glargine) 20 units at bedtime to a patient's regimen of Jardiance (empagliflozin) 10 mg daily and metformin 500 mg twice daily, with an A1c of 6.9 and blood sugars in the 200s?

Should Lantus 20 Units Be Added at Bedtime?

No, do not add Lantus 20 units at bedtime—this patient needs a comprehensive medication optimization strategy that includes increasing metformin, titrating Jardiance, and then initiating basal insulin at a lower, evidence-based starting dose of 10 units daily if still needed.

Critical Problems with the Proposed Approach

Metformin is Severely Under-Dosed

• This patient is only on metformin 500 mg twice daily (1000 mg total), which is far below the therapeutic range. The American Diabetes Association recommends increasing metformin to at least 1000 mg twice daily (2000 mg total), with a maximum effective dose of up to 2500 mg/day 1.
• Metformin should be continued and optimized when adding or intensifying insulin therapy, as it reduces total insulin requirements and provides complementary glucose-lowering effects 1.

Jardiance Dose is Suboptimal

• The patient is on Jardiance 10 mg daily, which can be increased to 25 mg daily for additional glucose-lowering effect if tolerated 2.
• SGLT2 inhibitors like Jardiance provide cardiovascular and kidney disease risk reduction benefits that should be maximized before advancing to insulin 2.

The Proposed Lantus Dose is Too High for Insulin Initiation

• The American Diabetes Association explicitly recommends starting basal insulin at 10 units once daily OR 0.1-0.2 units/kg body weight for insulin-naive patients with type 2 diabetes 1, 3.
• Starting at 20 units significantly exceeds guideline-recommended initial dosing and increases hypoglycemia risk without evidence of superior efficacy 1.

The Correct Stepwise Approach

Step 1: Optimize Foundation Therapy First (Next 3-6 Months)

• Increase metformin to 1000 mg twice daily (2000 mg total daily dose) unless contraindicated by renal function or gastrointestinal intolerance 1.
• Consider increasing Jardiance from 10 mg to 25 mg daily if the patient tolerates the current dose without adverse effects 2.
• Reassess A1C in 3 months after these medication adjustments 2.

Step 2: If A1C Remains Above Goal After Optimizing Oral Agents

• Initiate Lantus at 10 units once daily (not 20 units), administered at the same time each day 1, 3.
• The recommended starting dosage is 0.2 units/kg or up to 10 units once daily for patients with type 2 diabetes not currently treated with insulin 3.
• Continue metformin at the optimized dose and maintain Jardiance unless contraindicated 1.

Step 3: Titrate Lantus Using Evidence-Based Algorithm

• Increase Lantus by 2 units every 3 days if fasting glucose is 140-179 mg/dL 1.
• Increase Lantus by 4 units every 3 days if fasting glucose is ≥180 mg/dL 1.
• Target fasting plasma glucose of 80-130 mg/dL 1.
• If hypoglycemia occurs without clear cause, reduce the dose by 10-20% immediately 1.

Step 4: Monitor for Critical Threshold

• When basal insulin exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, consider adding prandial insulin rather than continuing to escalate basal insulin alone 1.
• Clinical signals of overbasalization include basal dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, and high glucose variability 1.

Why Blood Sugars in the 200s with A1C 6.9 Requires Investigation

This Discrepancy Suggests Specific Glucose Patterns

• An A1C of 6.9 with blood sugars consistently in the 200s suggests significant postprandial hyperglycemia with relatively controlled fasting glucose 2.
• This pattern indicates the need to address meal-related glucose excursions, not just add basal insulin 2.
• The patient may benefit from adding a GLP-1 receptor agonist to address postprandial hyperglycemia while minimizing weight gain and hypoglycemia risk 2, 1.

Timing of Blood Glucose Measurements Matters

• If the 200s readings are postprandial (after meals), this confirms inadequate mealtime coverage that basal insulin alone will not address 2.
• If the 200s readings are fasting, then basal insulin optimization is appropriate, but starting at 10 units (not 20 units) is the evidence-based approach 1, 3.

Common Pitfalls to Avoid

Never Start Insulin at Doses Higher Than Guidelines Recommend

• Starting at 20 units without prior insulin exposure significantly increases hypoglycemia risk without evidence of benefit 1.
• The FDA-approved starting dose for insulin-naive type 2 diabetes patients is 0.2 units/kg or up to 10 units once daily 3.

Never Add Insulin Without First Optimizing Metformin

• Metformin should be at therapeutic doses (≥2000 mg daily) before advancing to insulin therapy 1.
• The combination of metformin and basal insulin provides superior glycemic control with reduced insulin requirements and less weight gain compared to insulin alone 1.

Never Delay Proper Titration Once Insulin is Started

• Daily fasting blood glucose monitoring is essential during titration 1.
• Adjust the dose every 3 days based on fasting glucose patterns until target is reached 1.
• Therapeutic inertia (delaying appropriate dose adjustments) prolongs hyperglycemia exposure and increases complication risk 2.

Patient Education Requirements Before Starting Insulin

Essential Skills and Knowledge

• Proper insulin injection technique and site rotation to prevent lipodystrophy 1, 3.
• Recognition and treatment of hypoglycemia with 15 grams of fast-acting carbohydrate 1.
• Self-monitoring of blood glucose, particularly fasting glucose during titration 1.
• "Sick day" management rules and when to contact healthcare provider 1.
• Insulin storage and handling to maintain potency 1.