Managing Hypoglycemia Risk with Empagliflozin and Insulin

Introduction to Empagliflozin and Insulin Therapy

The American Diabetes Association recommends reducing insulin doses by 10-20% when hypoglycemia occurs or when adding complementary therapies, such as empagliflozin, to mitigate hypoglycemia risk 1
A 17% insulin dose reduction, from 30 to 25 units, aligns with guideline recommendations to reduce hypoglycemia-causing medications when adding new glucose-lowering agents, such as empagliflozin 2

Check fasting blood glucose daily to establish baseline response to the combination therapy of empagliflozin and insulin 1
Set a fasting plasma glucose target of 80-130 mg/dL (4.4-7.2 mmol/L) for patients on empagliflozin and insulin therapy 1, 3
Increase Novomix by 4 units every 3 days if fasting glucose ≥180 mg/dL, as part of an insulin titration algorithm for patients on empagliflozin 1, 3
Increase Novomix by 2 units every 3 days if fasting glucose 140-179 mg/dL, as part of an insulin titration algorithm for patients on empagliflozin 1, 3

Consider transitioning to a basal-bolus regimen if fasting glucose <140 mg/dL but HbA1c remains >7% at 3 months, as premixed insulin may not be optimal for patients with severe hyperglycemia 4, 5
Convert to basal insulin (50-60% of current total daily dose) plus rapid-acting insulin before meals (starting with 4 units or 10% of basal dose per meal) for patients who require a basal-bolus regimen 1, 5

Determine the cause of hypoglycemia (missed meal, increased activity, timing issues) and reduce the corresponding insulin dose by 10-20% if no clear reason is identified 1
Treat hypoglycemia with 15-20g of rapid-acting carbohydrate and recheck glucose in 15 minutes, according to the American Diabetes Association guidelines 6

Do not continue premixed insulin indefinitely if control remains poor, as premixed formulations have suboptimal pharmacodynamic profiles for covering postprandial glucose excursions 5
Do not fear insulin titration with an HbA1c level of 10.1%, as severe hyperglycemia poses greater immediate risk than potential hypoglycemia 7
Ensure patients understand hypoglycemia symptoms, have glucose monitoring supplies, and know when to contact their healthcare provider, as part of diabetes self-management education 1, 2