How to manage a patient with type 1 diabetes mellitus (T1DM) and an elevated Hemoglobin A1C (HbA1C) level, who is currently on a regimen of 32 units of long-acting insulin at bedtime and 4 units of short-acting insulin three times a day, but refuses to self-monitor blood glucose levels and has no insurance?

Management of Type 1 Diabetes with Poor Glycemic Control and No Self-Monitoring

For a patient with T1DM, an A1c of 13%, on 32 units of long-acting insulin at bedtime and 4 units of short-acting insulin TID, who refuses to check blood glucose and has no insurance, the most effective approach is to intensify insulin therapy while implementing a structured monitoring plan at clinic visits.

Current Regimen Assessment

• The patient's A1c of 13% indicates extremely poor glycemic control, significantly above the recommended target of <7% for most adults with T1DM 1
• The current insulin regimen (32 units long-acting at bedtime and 4 units short-acting TID) is likely inadequate for a patient with such poor control 2
• Self-monitoring of blood glucose (SMBG) is a critical component of T1DM management, and the patient's refusal presents a significant barrier to optimal care 1
• Lack of insurance creates additional challenges for accessing supplies and medications 1

Insulin Regimen Adjustment

• Increase the basal insulin dose by 2-4 units every 3-7 days until fasting blood glucose reaches target levels, based on clinic measurements 2, 3
• Increase the prandial insulin doses from 4 units to at least 10% of the total daily basal dose (approximately 3-4 units initially), with further adjustments based on clinic glucose readings 2, 3
• Consider splitting the long-acting insulin into twice-daily dosing to provide more consistent coverage throughout the day 1, 3
• Rapid-acting insulin should be administered before each meal to better control postprandial glucose excursions 1, 3

Monitoring Strategy Without Self-Monitoring

• Schedule frequent clinic visits (every 1-2 weeks initially) to check blood glucose levels and adjust insulin doses accordingly 1
• Consider point-of-care A1c testing at each visit to allow for more timely treatment changes 1
• If available, provide a clinic glucose meter for use during visits to document patterns 1
• Explore community resources or patient assistance programs that might provide free or low-cost glucose meters and strips 1

Patient Education and Support

• Provide targeted education about the importance of glucose monitoring and the risks of poorly controlled diabetes, focusing on complications that affect quality of life 1
• Teach the patient to recognize and respond to symptoms of hypoglycemia and hyperglycemia, even without a meter 1
• Instruct the patient to carry fast-acting carbohydrates (at least 15g) at all times to treat hypoglycemia 1
• Educate family members or roommates about glucagon administration for severe hypoglycemia 1

Addressing Barriers to Care

• Investigate patient assistance programs from insulin manufacturers for uninsured patients 1
• Connect the patient with social services that may help with obtaining insurance coverage 1
• Consider less expensive insulin options if cost is a barrier (e.g., human insulins available at lower cost from certain pharmacies) 1
• Address potential psychological barriers to self-monitoring through motivational interviewing techniques 1

Long-term Considerations

• If resources become available, continuous glucose monitoring (CGM) would be beneficial for this patient, especially given the refusal to perform SMBG 1
• For patients with significant hyperglycemia (A1c >10%), more aggressive insulin therapy is warranted to reduce the risk of diabetic ketoacidosis 2, 3
• Regular assessment for complications should be performed given the poor glycemic control 1
• The goal should be to gradually bring the A1c down to <7% to reduce the risk of microvascular and macrovascular complications 1, 4

Common Pitfalls to Avoid

• Don't rely solely on A1c for treatment decisions in the absence of regular SMBG data 1, 5
• Avoid rapid reduction in A1c which can precipitate hypoglycemic events 3
• Don't discontinue insulin therapy even during illness when the patient may be unable to eat 1
• Don't assume non-compliance with monitoring indicates non-compliance with medication; continue to optimize the insulin regimen 1