Immediate Addition of Basal Insulin to Empagliflozin
At an HbA1c of 10.7%, empagliflozin alone is insufficient—you must immediately add basal insulin while continuing empagliflozin for its cardiovascular and renal protection. 1
Why Insulin Is Mandatory at This HbA1c Level
The American Diabetes Association classifies HbA1c ≥10% as an absolute indication for insulin therapy because oral agents typically lower HbA1c by only 0.5–1.1%, which cannot bring a patient from 10.7% to the target of <7%. 1
Empagliflozin reduces HbA1c by approximately 0.6–0.8% when added to existing therapy, meaning it would only lower your patient's HbA1c to roughly 10.0%—still dangerously elevated. 2, 3
Delaying insulin initiation at this level prolongs exposure to severe hyperglycemia, accelerating microvascular and macrovascular complications. 1
Basal Insulin Initiation Protocol
Start basal insulin (NPH or long-acting analog such as glargine or detemir) at 10 units once daily at bedtime, or calculate 0.2 units/kg body weight given the severity of hyperglycemia. 1
Titrate the dose by 2–4 units every 3 days until fasting glucose reaches 80–130 mg/dL (4.4–7.2 mmol/L) without hypoglycemia. 1
If hypoglycemia occurs, identify the cause and reduce the insulin dose by 10–20% immediately. 1
Continue Empagliflozin for Organ Protection
Do not discontinue empagliflozin when adding insulin—it provides cardiovascular and renal protection that is independent of its glucose-lowering effect. 4, 2
Empagliflozin reduces cardiovascular death and heart-failure hospitalization even when HbA1c is already at goal, so its benefits persist throughout insulin intensification. 2
The combination of empagliflozin plus basal insulin has been studied in a 78-week randomized trial: empagliflozin 10 mg and 25 mg added to basal insulin reduced HbA1c by 0.6% and 0.7% respectively at 18 weeks, and significantly reduced weight and insulin dose requirements at 78 weeks without increasing hypoglycemia risk. 5
Add Metformin if Not Already Prescribed
If the patient is not on metformin, start metformin 500 mg twice daily with meals and titrate to 2000 mg daily (1000 mg twice daily) to maximize glucose-lowering and provide cardiovascular mortality benefit. 1
Metformin lowers insulin requirements, mitigates insulin-associated weight gain, and carries minimal hypoglycemia risk when combined with basal insulin. 1
Continue metformin throughout insulin intensification unless eGFR falls below 30 mL/min/1.73 m². 1
Next Step: Add a GLP-1 Receptor Agonist if HbA1c Remains >7% After 3 Months
Reassess HbA1c at 3 months; if it remains >7% despite optimized basal insulin, add a GLP-1 receptor agonist (semaglutide, liraglutide, or dulaglutide) rather than further increasing insulin dose. 1, 6
GLP-1 receptor agonists provide an additional 0.6–0.8% HbA1c reduction, promote 2–5 kg weight loss, carry minimal hypoglycemia risk, and have proven cardiovascular benefit in high-risk patients. 1, 6
The combination of empagliflozin + GLP-1 receptor agonist + basal insulin maximizes cardiorenal protection while achieving glycemic targets. 6
Monitoring and Safety
Check fasting glucose daily during insulin titration to guide dose adjustments. 1
Verify renal function (eGFR) before starting or continuing empagliflozin; it can be used safely down to eGFR ≥20 mL/min/1.73 m². 6
Educate the patient to stop empagliflozin and seek urgent care if they develop nausea, vomiting, abdominal pain, or dyspnea—signs of euglycemic diabetic ketoacidosis. 4
Critical Pitfalls to Avoid
Do not wait to see if empagliflozin alone will work at HbA1c 10.7%—it will not bring the patient to target, and therapeutic inertia increases complication risk. 1
Do not discontinue empagliflozin when adding insulin; it provides complementary organ-protective benefits that are independent of glycemic control. 4, 2
Do not add sulfonylureas to this regimen—they markedly increase hypoglycemia risk when combined with insulin and lack the cardiovascular benefits of GLP-1 receptor agonists. 1
Do not delay intensification beyond 3 months if HbA1c remains above target; prolonged hyperglycemia exposure accelerates complications. 1