Management of Elevated HbA1c in Patients on Empagliflozin and Insulin

Assessment and Treatment Adjustments

The American College of Physicians and the American Diabetes Association recommend transitioning from NPH 70/30 insulin to a basal-bolus insulin regimen while maintaining empagliflozin for patients with significant HbA1c increase, indicating inadequate glycemic control with the current regimen 1, 2
The patient's HbA1c has increased significantly from 7.9% to 9.2% over 3 months, indicating inadequate glycemic control with the current regimen of empagliflozin and NPH 70/30 insulin, according to the American College of Physicians 1
Premixed insulin analogues like 70/30 have suboptimal pharmacodynamic profiles for covering postprandial glucose excursions, which may be contributing to the poor control, as stated by the American Diabetes Association 1
The American Diabetes Association recommends starting with a basal insulin at approximately 50-60% of the current total daily insulin dose and adding rapid-acting insulin before meals, starting with 4 units or 10% of the total daily insulin dose before each meal 2, 4

The American Diabetes Association recommends adjusting basal insulin dose by 1-2 units once or twice weekly until fasting blood glucose reaches target, and titrating prandial insulin doses by 1-2 units twice weekly based on postprandial glucose readings 2, 4, 5
The American College of Physicians recommends self-monitoring of blood glucose daily during the titration phase and scheduling follow-up within 2-4 weeks to assess response to the new regimen 4, 6
The American Diabetes Association recommends targeting an HbA1c of <7.0-7.5% depending on the patient's age and comorbidities, with a strength of evidence level of A 5, 7

Basal-bolus insulin therapy provides more precise and flexible prandial coverage than premixed insulin, according to the American Diabetes Association, with a moderate strength of evidence 2, 4
The American College of Physicians recommends avoiding common pitfalls such as continuing with premixed insulin despite poor control, not reducing basal insulin when adding prandial insulin, and delaying insulin regimen intensification despite poor glycemic control 1, 2, 6