What is the best course of action for a patient with hyperglycemia (elevated Hemoglobin A1c (HbA1c)) who is reluctant to use long-acting insulin?

Management of Patient with HbA1c of 13% Who Refuses Long-Acting Insulin

A patient with an HbA1c of 13% who refuses long-acting insulin should be referred to an endocrinologist due to the severely uncontrolled hyperglycemia and need for specialized diabetes management. 1

Rationale for Endocrinology Referral

Severity of Hyperglycemia

• An HbA1c of 13% indicates severely uncontrolled diabetes with significantly elevated risk of complications
• According to ADA guidelines, patients with very high HbA1c (>10%) often require specialized management 2
• The magnitude of required A1c reduction (approximately 6% to reach target) typically necessitates multiple medication adjustments and close monitoring

Complex Treatment Decisions Required

• Patient refusal of long-acting insulin creates a therapeutic challenge that requires specialized expertise
• Standard algorithms for severe hyperglycemia typically recommend insulin therapy when HbA1c exceeds 9-10% 2, 3
• Alternative regimens for patients refusing insulin require careful consideration of:
  • Risk of acute complications (diabetic ketoacidosis, hyperosmolar state)
  • Medication combinations that can effectively lower such severely elevated glucose
  • More frequent monitoring and dose adjustments

Alternative Treatment Options While Awaiting Endocrinology Consultation

While referral to endocrinology is the primary recommendation, the following interim measures can be considered:

1. Initiate or optimize oral combination therapy:

   • Metformin (if not contraindicated) as foundation therapy 2
   • Consider adding an SGLT2 inhibitor for complementary mechanism and cardiovascular benefits 2
   • Add a GLP-1 receptor agonist if possible, as these can provide significant A1c reductions (2-2.5%) in patients with very high baseline levels 3

2. Consider fixed-dose combinations to improve medication adherence 2

3. Implement intensive lifestyle modifications:

   • Structured diabetes education program
   • 150 minutes/week of moderate-intensity physical activity
   • Medical nutrition therapy with low-carbohydrate or Mediterranean diet approach 2

4. Increase monitoring frequency:

   • Home glucose monitoring 3-4 times daily
   • Follow-up within 2 weeks to assess response and adjust therapy

Common Pitfalls to Avoid

• Delayed intensification of therapy - With HbA1c of 13%, immediate action is required to prevent complications 2
• Underestimating the severity - An HbA1c of 13% indicates average blood glucose of approximately 330 mg/dL, posing immediate risks
• Ignoring patient concerns about insulin - Understanding specific concerns about long-acting insulin may reveal alternatives acceptable to the patient
• Failing to consider non-adherence factors - Financial, social, or psychological barriers may be contributing to medication refusal

Key Points for Discussion with Patient

1. Explain the severity of hyperglycemia and associated risks in clear terms
2. Discuss that while alternatives exist, insulin is typically the most effective option for HbA1c >10% 3
3. Address specific concerns about insulin therapy (fear of injections, hypoglycemia, weight gain)
4. Emphasize that endocrinology consultation provides specialized expertise to find the best individualized approach

The urgent need for specialized care in this case is supported by the ADA guidelines, which indicate that patients with complex diabetes management issues, including those unable or unwilling to use recommended therapies, benefit from referral to specialists with expertise in diabetes management 1.