What is the optimal management plan for a patient with type 2 diabetes mellitus, diabetic polyneuropathy, essential hypertension, chronic anemia, severe vitamin D deficiency, and chronic low back pain upon discharge?

Optimal Discharge Management Plan for Complex Type 2 Diabetes with Multiple Comorbidities

This patient requires immediate insulin regimen optimization with increased prandial insulin dosing, continuation of metformin, aggressive vitamin D repletion for neuropathy management, and structured home health monitoring to address the persistently elevated glucose levels (A1C 8.8%) and severe vitamin D deficiency contributing to neuropathic symptoms. 1

Glycemic Management Priority

Insulin Regimen Adjustment

• Increase NovoLog (prandial insulin) from current dosing to 8-10 units three times daily before meals to address the persistent postprandial hyperglycemia (glucose readings ranging 152-285 mg/dL throughout admission) 1
• Continue Lantus at bedtime but adjust dose by 10-20% if hypoglycemia occurs, targeting fasting glucose 80-130 mg/dL 1, 2
• The current A1C of 8.8% with wide glucose fluctuations (96-285 mg/dL) indicates inadequate prandial coverage despite basal insulin optimization 1

Metformin Continuation

• Continue metformin as the foundation of therapy given eGFR of 82 mL/min/1.73m², which is well above the safety threshold 2
• Metformin should be maintained when used in combination with insulin therapy and provides additional benefit for insulin sensitivity 1
• Monitor for vitamin B12 deficiency given the patient's existing anemia and neuropathy—periodic supplementation is recommended if levels are deficient 2

Home Glucose Monitoring Protocol

• Check fasting glucose daily and pre-meal glucose before each meal to guide insulin adjustments 1
• Check 2-hour postprandial glucose after the largest meal to assess prandial insulin effectiveness 1
• Adjust NovoLog dose by 1-2 units or 10-15% every 3-7 days based on postprandial readings, targeting <180 mg/dL 1

Diabetic Polyneuropathy Management

Vitamin D Repletion as Primary Intervention

• Aggressively treat the severe vitamin D deficiency (level 9.4 ng/mL) with ergocalciferol continuation, as vitamin D deficiency is directly associated with worsening neuropathic symptoms and lower pain thresholds 3, 4
• Vitamin D supplementation has demonstrated dramatic improvement in severe diabetic neuropathy symptoms, including cases requiring narcotic management 3
• Pain improvement with vitamin D therapy may be independent of baseline vitamin D level but related to the absolute value attained following supplementation 5

Neuropathic Pain Management

• Continue gabapentin for neuropathic pain as currently prescribed—this is an evidence-based agent for diabetic peripheral neuropathy with typical dosing 300-1,200 mg three times daily 2
• Continue PRN acetaminophen for breakthrough pain management 2
• The patient's current pain score of 2/10 suggests adequate control, but monitor closely as glucose optimization may further improve neuropathic symptoms 4

Cardiovascular and Blood Pressure Management

Orthostatic Hypertension Control

• Cardiology follow-up within 1 week is critical given the wide orthostatic fluctuations and standing systolic readings >180 mmHg during admission 2
• Isosorbide mononitrate was appropriately discontinued due to paradoxical hypertension 2
• SGLT2 inhibitors should be used with caution given the documented orthostatic hypotension and concurrent diuretic/ACE inhibitor use 2

Consideration for SGLT2 Inhibitor or GLP-1 RA

• Consider adding an SGLT2 inhibitor with proven cardiovascular benefit (empagliflozin or canagliflozin) given the patient's cardiovascular risk profile including history of TIA, hypertension, and aortic regurgitation 2
• SGLT2 inhibitors can be initiated with eGFR ≥20 mL/min/1.73m² and provide cardiorenal protection independent of glucose-lowering effects 2
• However, monitor closely for dehydration, acute kidney injury, and orthostatic hypotension given existing autonomic dysfunction 2
• Alternative: GLP-1 receptor agonist with proven cardiovascular benefit if SGLT2i not tolerated, which would also address weight management post-gastric bypass 2, 1

Anemia and Nutritional Management

Iron Deficiency Treatment

• Continue ferrous sulfate supplementation for mild iron deficiency (Hgb 10.8, Hct 31.8) 6
• Iron deficiency anemia treatment in T2DM patients can significantly reduce blood glucose and insulin resistance levels 6
• Monitor hemoglobin and iron studies in 3 months to assess response 6

Post-Gastric Bypass Nutritional Support

• Continue nutritional supplements to address mild hypoalbuminemia (albumin 3.6) 2
• Maintain consistent carbohydrate intake with diabetic-appropriate diet to improve insulin dosing accuracy 1
• Follow low-sodium (<2 g/day), cardiac-friendly diet given hypertension and cardiovascular risk 2, 7

Home Health Services and Monitoring

Structured Follow-Up Plan

• PCP and cardiology appointments within 1 week of discharge are mandatory given uncontrolled diabetes and cardiovascular complications 2
• Home health nursing to monitor glucose patterns, insulin administration technique, and medication adherence 2, 1
• Physical therapy/occupational therapy to continue for mobility and fall prevention given neuropathy and orthostatic issues 2

Patient Education Priorities

• Hypoglycemia recognition and treatment with 15-20 grams of fast-acting carbohydrate 1
• Proper insulin injection technique with 90-degree angle and systematic site rotation within one anatomical area 1
• Signs requiring immediate medical attention: glucose <70 mg/dL, dizziness with standing, chest pain, or signs of infection 2

A1C Monitoring

• Recheck A1C in 3 months to assess response to intensified insulin regimen and vitamin D repletion 1
• Target A1C <7-8% is reasonable given age, comorbidities, and hypoglycemia risk, though individualization based on response is appropriate 2

Critical Pitfalls to Avoid

• Do not delay insulin intensification—the patient's glucose readings (multiple values >200 mg/dL) with A1C 8.8% require immediate action 1
• Do not discontinue metformin despite insulin use—it remains foundational therapy and improves insulin sensitivity 2, 1
• Do not overlook vitamin D deficiency as a treatable contributor to neuropathic pain—this is a modifiable factor that may dramatically improve symptoms 3, 4, 5
• Do not reduce insulin doses prematurely if mild hyperglycemia persists—the risk of hyperglycemic complications outweighs modest glucose elevations in this stable patient 2
• Do not ignore the emotional distress—continue supportive counseling and consider mental health referral if symptoms persist, as depression affects diabetes self-management 2