What should be added to a type 2 diabetic on empagliflozin (Jardiance) and insulin glargine (Lantus) 10 U with glucose ~300 mg/dL?

Immediate Insulin Intensification Required

You must immediately increase the Lantus dose and add prandial insulin coverage—10 units of basal insulin is grossly inadequate for blood glucose in the 300s, and this patient requires aggressive insulin intensification now.

Critical Problems with Current Regimen

• Severe under-dosing of basal insulin: 10 units of Lantus is far below the recommended starting dose for patients with severe hyperglycemia 1
• Blood glucose in the 300s indicates both inadequate basal coverage AND likely insufficient mealtime coverage, requiring both basal insulin titration and prandial insulin addition 1
• Jardiance (empagliflozin) alone cannot compensate for this degree of insulin deficiency—SGLT2 inhibitors provide modest HbA1c reductions of 0.5-0.7% and are not designed to manage severe hyperglycemia 2, 3, 4

Immediate Action Plan

Step 1: Aggressively Titrate Basal Insulin

• Increase Lantus by 4 units every 3 days until fasting glucose reaches 80-130 mg/dL, as blood glucose ≥300 mg/dL warrants rapid escalation 1
• For severe hyperglycemia like this, consider starting doses of 0.3-0.5 units/kg/day as total daily insulin, which for most patients would be 20-40 units/day total 1
• Target fasting glucose: 80-130 mg/dL 1

Step 2: Add Prandial Insulin Coverage Immediately

• Start with 4 units of rapid-acting insulin (lispro, aspart, or glulisine) before the largest meal, or use 10% of the basal dose 1
• Administer 0-15 minutes before meals for optimal postprandial control 1
• Titrate prandial insulin by 1-2 units every 3 days based on 2-hour postprandial glucose readings 1
• Target postprandial glucose: <180 mg/dL 1

Step 3: Optimize Foundation Therapy

• Continue metformin at maximum tolerated dose (up to 2000-2550 mg daily) unless contraindicated—the combination of metformin with insulin provides superior glycemic control with reduced insulin requirements and less weight gain 1
• Continue Jardiance (empagliflozin)—SGLT2 inhibitors provide complementary glucose-lowering through urinary glucose excretion and offer cardiovascular benefits in patients with established cardiovascular disease 1

Why This Aggressive Approach Is Necessary

• Blood glucose in the 300s reflects complete inadequacy of current insulin dosing, not merely a need for minor adjustments 1
• Studies show that patients with severe hyperglycemia (HbA1c ≥9%, glucose ≥300-350 mg/dL) require immediate basal-bolus insulin therapy rather than basal insulin alone 1
• Delaying insulin intensification prolongs exposure to severe hyperglycemia and increases complication risk 1

Monitoring Requirements

• Daily fasting blood glucose monitoring is essential during titration 1
• Check pre-meal and 2-hour postprandial glucose to guide prandial insulin adjustments 1
• Reassess HbA1c after 3 months to determine if additional intensification is needed 1

Critical Threshold Warning

• When basal insulin exceeds 0.5 units/kg/day (typically 35-50 units for most patients), adding or intensifying prandial insulin becomes more appropriate 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

Common Pitfalls to Avoid

• Never delay insulin intensification in patients not achieving glycemic goals—this prolongs hyperglycemia exposure and increases complication risk 1
• Never discontinue metformin when intensifying insulin unless contraindicated—this leads to higher insulin requirements and more weight gain 1
• Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia—this leads to overbasalization with increased hypoglycemia risk and suboptimal control 1

Patient Education Essentials

• Hypoglycemia recognition and treatment: Treat any glucose <70 mg/dL immediately with 15 grams of fast-acting carbohydrate 1
• Proper insulin injection technique and site rotation 1
• Self-monitoring of blood glucose and "sick day" management rules 1
• Insulin storage and handling 1

Expected Outcomes

• With appropriate basal-bolus therapy at weight-based dosing, expect HbA1c reduction of 2-3% from baseline over 3-6 months 1
• 68% of patients achieve mean blood glucose <140 mg/dL with proper basal-bolus therapy versus only 38% with inadequate insulin regimens 1