From the Guidelines
The optimal discharge plan for a 65-year-old male with poorly controlled type 1 diabetes mellitus and uncontrolled hypertension should prioritize medication management, monitoring, education, and follow-up care to reduce morbidity and mortality risk. The patient's current insulin regimen appears inadequate, and adjusting to a basal-bolus insulin regimen with long-acting insulin (such as insulin glargine 20-30 units at bedtime) and rapid-acting insulin (such as insulin lispro or aspart) before meals based on carbohydrate counting and correction factors is recommended 1. For hypertension management, a combination therapy with an ACE inhibitor (lisinopril 10-20 mg daily) and a calcium channel blocker (amlodipine 5-10 mg daily) is likely needed, with a blood pressure goal of <130/80 mmHg 1. Key aspects of the discharge plan include:
- Blood glucose monitoring 4 times daily (before meals and at bedtime) with target fasting glucose of 80-130 mg/dL and post-meal glucose below 180 mg/dL
- Home blood pressure monitoring twice daily
- Dietary recommendations: low-sodium diet (<2,300 mg daily) and carbohydrate-consistent meals
- Diabetes education focusing on insulin administration, hypoglycemia management, and carbohydrate counting
- Follow-up appointments within 1-2 weeks with both primary care and endocrinology Given the patient's hypoglycemic unawareness, it is crucial to advise increasing glycemic targets for at least several weeks to partially reverse hypoglycemia unawareness and reduce the risk for future episodes 1. Additionally, the discharge plan should emphasize the importance of regular physical activity, smoking cessation (if applicable), and a healthy diet to modify risk factors and improve outcomes 1. A structured discharge plan tailored to the individual patient's needs, as recommended by the 2020 standards of medical care in diabetes, is essential to reduce length of hospital stay, readmission rates, and increase patient satisfaction 1.
From the FDA Drug Label
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From the Research
Discharge Plan for a 65-year-old Male with Poorly Controlled Type 1 Diabetes Mellitus and Uncontrolled Hypertension
The patient's discharge plan should focus on optimizing his insulin regimen, managing his hypertension, and providing comprehensive education on disease management to prevent end-organ damage and reduce morbidity/mortality risk.
- Insulin Regimen Adjustment: Consider switching to a basal-bolus insulin regimen using insulin analogues such as insulin detemir or insulin glargine, which have been shown to provide better glycemic control with lower risk of hypoglycemia compared to traditional human insulins 2, 3, 4, 5, 6.
- Hypertension Management: Initiate or adjust antihypertensive medications to achieve a blood pressure target of less than 140/90 mmHg, considering the patient's diabetes status and cardiovascular risk factors.
- Comprehensive Education: Provide patient education on:
- Proper insulin administration and dosing
- Blood glucose monitoring and target ranges
- Hypoglycemia recognition and treatment
- Healthy lifestyle habits, including diet and exercise
- Medication adherence and potential side effects
- Close Observation and Follow-up: Schedule regular follow-up appointments with the patient's healthcare provider to monitor his glycemic control, blood pressure, and overall health status, making adjustments to his treatment plan as needed.
- Multidisciplinary Care: Consider involving a multidisciplinary team, including a diabetes educator, dietitian, and pharmacist, to provide comprehensive care and support for the patient's diabetes and hypertension management.