What is the best management plan for a non-compliant T2DM patient with diabetic neuropathy and uncontrolled blood sugar levels?

Management of Non-Compliant T2DM with Diabetic Neuropathy and Uncontrolled Hyperglycemia

This patient requires immediate insulin therapy combined with metformin reinitiation and neuropathic pain management, as the HbA1c of 9.7% with symptomatic hyperglycemia mandates prompt intensive intervention to prevent further microvascular complications. 1

Rationale for Insulin Initiation

Patients with T2DM presenting with HbA1c >9% should initiate insulin therapy as soon as possible, ideally within 3 months of recognition of failure of lifestyle intervention and oral medication therapies. 1

• The starting dose of insulin glargine at 0.2 units/kg (approximately 10 units for this patient's weight) is appropriate for insulin-naive T2DM patients, though the prescribed 14 units is reasonable given the severe hyperglycemia. 2
• Short-term intensive insulin treatment (2 weeks to 3 months) can be implemented in newly diagnosed or poorly controlled patients with HbA1c >9.0% or FPG ≥11.1 mmol/L, which allows for quicker restoration of glycemic control and may allow beta cells to "rest and recover." 1
• Many patients can be gradually weaned from insulin therapy and subsequently managed with metformin and lifestyle modification once glycemic control is achieved. 1

Metformin Reinitiation is Critical

Metformin should be restarted and remain as the foundation of therapy, as it is the preferred first-line agent for T2DM with established cardiovascular and mortality benefits. 1

• The patient's fear of renal side effects is unfounded given his normal creatinine (83 μmol/L, approximately 0.94 mg/dL) and BUN (4.90 mmol/L). 1
• Metformin can be safely continued in patients with declining renal function down to a GFR of 30-45 mL/min, although the dose should be reduced at lower GFR levels. 1
• Starting at 500 mg BID is appropriate, with gradual titration up to 2000 mg daily in divided doses to minimize gastrointestinal side effects. 1
• The main gastrointestinal adverse effects (abdominal pain, bloating, loose stools) are often transient and diminish as treatment time increases. 1

Diabetic Neuropathy Management

Pregabalin 75 mg once daily is an appropriate initial dose for painful diabetic neuropathy, though this represents symptomatic treatment only. 3

• The patient's symptoms of "pins and needles" (paresthesias) with pain score 5/10 in hands and feet are classic for distal symmetric polyneuropathy, the most common form of diabetic neuropathy. 4
• Poor glycemic control (HbA1c 9.7%) and the 5-year duration of uncontrolled diabetes are significant risk factors for diabetic peripheral neuropathy. 5
• Achieving glycemic control is the most important intervention to prevent progression of neuropathy, though the benefit is more modest in T2DM compared to type 1 diabetes. 6

Critical Monitoring and Follow-up Strategy

Daily fasting blood glucose monitoring for 7 days is insufficient for this patient; four-times-daily monitoring (fasting and 2 hours post-meals) is recommended when initiating insulin therapy. 1, 2

• Target glucose levels should be 5-10 mmol/L (90-180 mg/dL) fasting and <10 mmol/L postprandially. 1
• Close monitoring for hypoglycemia is essential, particularly in patients with diabetic neuropathy who may have reduced symptomatic awareness of hypoglycemia. 2
• Self-monitoring of blood glucose plays an essential role in the prevention and management of hypoglycemia, especially during insulin initiation. 2

Insulin Dose Titration Plan

The insulin glargine dose should be titrated based on fasting glucose readings, increasing by 2-4 units every 3 days until fasting glucose targets are achieved. 2

• Changes in insulin regimen must be made under close medical supervision with increased frequency of blood glucose monitoring. 2
• For patients with type 2 diabetes, dosage adjustments of concomitant oral antidiabetic products may be needed as glycemic control improves. 2
• Patients should be educated to recognize and manage hypoglycemia, as severe hypoglycemia can cause seizures and may be life-threatening. 2

Addressing Non-Compliance

Patient education on the seriousness of uncontrolled diabetes and its complications is paramount, as initiation of insulin may increase long-term adherence by enhancing the patient's perception of disease severity. 1

• The presence of symptomatic neuropathy provides a tangible demonstration of diabetes complications that can be used to motivate adherence. 1
• Reassurance about metformin's renal safety profile with his normal kidney function should be explicitly provided to address his stated fear. 1

Additional Metabolic Considerations

The patient's low HDL (31 mg/dL) and borderline LDL (102.87 mg/dL) warrant attention, as dyslipidemia is a significant risk factor for diabetic peripheral neuropathy progression. 5

• Hyperlipidemia management should be addressed at follow-up, as cholesterol, LDL, and triglycerides are independent risk factors for diabetic neuropathy. 5
• The target LDL for patients with diabetes without established atherosclerotic cardiovascular disease is <2.6 mmol/L (<100 mg/dL). 1

Common Pitfalls to Avoid

Do not delay insulin intensification if fasting glucose remains >7.0 mmol/L after one week; treatment intensification should not be delayed when patients are not meeting treatment goals. 1

• Avoid focusing only on fasting glucose while overlooking postprandial glucose control, as both are essential for achieving HbA1c targets. 3
• Be aware of the potential for treatment-induced neuropathy (insulin neuritis) when rapidly improving glycemic control, though this should not deter appropriate treatment. 7
• Do not abruptly change injection sites if lipodystrophy develops, as sudden changes can precipitate hypoglycemia. 2
• Ensure patient education on proper insulin injection technique, glucose monitoring, and hypoglycemia recognition and management. 2

One-Week Follow-up Priorities

At the November 6 follow-up, assess fasting glucose trends, hypoglycemia episodes, neuropathic pain response, medication adherence, and adjust insulin dose accordingly. 1, 3

• If fasting glucose remains >7.0 mmol/L, increase insulin glargine by 2-4 units. 2
• If pregabalin provides insufficient pain relief, consider dose escalation or alternative agents. 3
• Reinforce metformin adherence and assess for gastrointestinal side effects. 1
• Schedule HbA1c reassessment in 3 months with target <7.0%. 1