What advice can be given to a 61-year-old male with type 1 diabetes mellitus (DM), hypertension, hyperlipidemia, anxiety, vitamin D deficiency, and reactive airway disease, presenting with hyperglycemia, elevated cholesterol, and fatigue, who has not been using his insulin/long-acting insulin therapy since February 2025 due to cost?

Management of Type 1 Diabetes with Severe Hyperglycemia and Fatigue

The patient's symptoms of fatigue, mental fogginess, and low mood are primarily caused by severe hyperglycemia (blood glucose 324 mg/dL) due to insulin non-adherence, and immediate resumption of insulin therapy is absolutely essential to prevent life-threatening diabetic ketoacidosis.

Immediate Interventions

1. Insulin Therapy Restoration

• Immediately restart insulin therapy - both basal and prandial insulin are essential for type 1 diabetes management 1
• Calculate total daily insulin requirement based on weight (0.4-1.0 units/kg/day) 1
• Distribute as approximately 50% basal insulin and 50% prandial insulin 1
• For a 61-year-old with type 1 diabetes, consider starting with 0.5 units/kg/day as recommended by ADA 1

2. Address Insulin Cost Barriers

• Connect patient with insulin assistance programs (manufacturer patient assistance programs)
• Consider lower-cost insulin options if needed (e.g., human insulins from community pharmacies)
• Explore Medicare/Medicaid coverage options if eligible

3. Glucose Monitoring

• Provide test strips as requested (essential for proper insulin dosing)
• Encourage frequent blood glucose monitoring (4+ times daily) 2
• Educate on target blood glucose range (110-180 mg/dL) 3
• Consider referral for continuous glucose monitoring if covered by insurance 1

Addressing Fatigue and Mental Health

1. Hyperglycemia-Related Symptoms

• Explain that fatigue, mental fogginess, and low mood are direct consequences of poor glycemic control
• Reassure that symptoms should improve with restored insulin therapy and normalized blood glucose
• Set expectations for timeline of symptom improvement (typically days to weeks)

2. Mental Health Support

• Screen for depression using standardized tools
• Consider referral to mental health professional if symptoms persist after glucose normalization
• Discuss stress management techniques

Cardiovascular Risk Management

1. Lipid Management

• Start statin therapy for elevated total cholesterol (232 mg/dL) despite normal HDL (61 mg/dL)
• Target LDL cholesterol <100 mg/dL, with option for <70 mg/dL as high-risk patient 1

2. Hypertension Management

• Ensure adherence to antihypertensive medications (BP 146/93 noted when medications missed)
• Target BP <130/80 mmHg 1

Pain Management

1. Chronic Pain Approach

• Discuss limitations of ASA for chronic pain management
• Consider referral to pain management specialist for comprehensive approach
• Evaluate for non-pharmacological options (physical therapy, etc.)

Patient Education

1. Diabetes Self-Management

• Reinforce that insulin should never be discontinued in type 1 diabetes 1
• Educate on signs/symptoms of hyperglycemia and diabetic ketoacidosis
• Provide sick-day management guidelines 1
• Teach carbohydrate counting for insulin dosing 1

2. Dietary Guidance

• Recommend heart-healthy diet with limited fat intake (<30% of calories, <7% saturated fat) 1
• Encourage whole grains, fruits, vegetables, and limited sodium intake (<1,500 mg/day) 1
• Discuss importance of regular meal timing with insulin administration

Follow-Up Plan

• Schedule follow-up within 1 week to assess response to insulin reinitiation
• Check HbA1c in 3 months to evaluate overall glycemic control
• Monitor for hypoglycemia risk with insulin resumption
• Consider endocrinology referral if glucose control remains suboptimal

Key Warnings and Precautions

• Warning: Insulin discontinuation in type 1 diabetes can rapidly lead to diabetic ketoacidosis, which is life-threatening 1
• Insulin dosing must be adjusted based on blood glucose monitoring results 4
• Hypoglycemia risk increases with insulin resumption - ensure patient can recognize and treat low blood glucose 4
• Testosterone supplementation is not indicated with normal testosterone level (668)

By addressing the severe hyperglycemia through insulin therapy resumption, the patient's fatigue, mental fogginess, and low mood should significantly improve, as these symptoms are direct consequences of poor glycemic control in type 1 diabetes.