What is the best plan to manage blood glucose in an 88-year-old male with type 2 diabetes mellitus in a skilled nursing facility?

Management of Blood Glucose in an 88-Year-Old Male in a Skilled Nursing Facility

The most appropriate plan to manage Carl's blood glucose in the skilled nursing facility is to discontinue the sliding-scale insulin aspart, continue insulin glargine, and resume the home regimen of metformin and semaglutide.

Rationale for This Approach

Assessment of Current Situation

• Patient is an 88-year-old male with type 2 diabetes (HbA1c 8.0%)
• Currently on sliding-scale insulin aspart (no doses required in past 2 days)
• Currently on insulin glargine 10 units at bedtime
• Home medications (withheld for 10 days): metformin 1000 mg BID and semaglutide 1 mg weekly
• Patient tolerated home medications well with no affordability issues
• Blood pressure is well-controlled
• Laboratory results are within normal limits

Evidence-Based Decision Making

Discontinuing Sliding-Scale Insulin

The American Diabetes Association strongly discourages the sole use of sliding scale insulin (SSI) in inpatient settings 1. For patients transitioning to skilled nursing facilities:

• SSI is ineffective as a standalone treatment and should be discontinued when the patient is stable 1
• Carl has not required any sliding-scale insulin doses in the past 2 days, indicating stable glycemic control
• Continuing SSI unnecessarily increases the risk of hypoglycemia, particularly in elderly patients 2

Continuing Basal Insulin (Glargine)

Maintaining basal insulin during care transitions is appropriate when:

• The patient has been stable on this regimen 1
• It provides consistent background glucose control 2
• The dose (10 units) appears appropriate as the patient has not experienced hypoglycemia

Resuming Home Medications

The American Diabetes Association emphasizes that care transitions are critical times to perform medication reconciliation 1. Resuming Carl's home regimen is supported by:

• His previous tolerance of these medications
• No contraindications in his current clinical state
• The complementary mechanisms of action between metformin, semaglutide, and basal insulin

Implementation Plan

1. Discontinue sliding-scale insulin aspart immediately

   • No longer needed as patient has not required doses for 2 days
   • Reduces risk of hypoglycemia in this elderly patient

2. Continue insulin glargine 10 units at bedtime

   • Maintains basal insulin coverage
   • Provides consistent background glucose control

3. Resume metformin 1000 mg BID

   • Effective oral agent with low hypoglycemia risk
   • Patient previously tolerated well

4. Resume semaglutide 1 mg weekly (on Sundays)

   • Provides additional glycemic control
   • Has complementary effects with metformin and basal insulin

Monitoring Recommendations

• Monitor blood glucose regularly, using a block testing approach (different times of day) rather than multiple daily checks 1
• Watch for hypoglycemia, especially during the first few days of medication adjustment
• Assess kidney function periodically due to metformin use in an elderly patient
• Evaluate for gastrointestinal side effects from resumed medications

Potential Pitfalls and How to Avoid Them

1. Risk of hypoglycemia

   • Monitor blood glucose more frequently during the transition period
   • Administer insulin glargine at consistent times
   • Consider dose reduction if hypoglycemia occurs

2. Medication interactions

   • Be aware that semaglutide may enhance the glucose-lowering effect of insulin
   • May need to adjust insulin glargine dose after semaglutide reaches steady state

3. Renal function concerns

   • Monitor renal function regularly due to metformin use in an elderly patient
   • Adjust metformin dose if GFR declines

4. Irregular dietary intake

   • Offer consistent carbohydrate meal plan rather than "no sugar" restrictions 1
   • Consider administering prandial insulin after meals if needed to match actual carbohydrate intake 1

This approach provides optimal glycemic control while minimizing hypoglycemia risk in this elderly patient transitioning to a skilled nursing facility. It appropriately balances the need for glucose control with safety considerations in the long-term care setting.