What is the recommended treatment for a patient with a hemoglobin A1c (HbA1c) of 6.5, history of diabetes with complications, including recent eye issues and recurrent infections, and fluctuating blood glucose levels, currently on a sliding scale regimen after being previously on human insulin (70/30 units, twice daily)?

Recommended Treatment for Uncontrolled Diabetes with Complications

This patient requires immediate transition from sliding scale insulin to a scheduled basal-bolus insulin regimen, with basal insulin titrated aggressively and prandial insulin added at meals to address the wide glycemic fluctuations (150-300 mg/dL) and prevent further complications. 1, 2

Why Sliding Scale Insulin Must Be Discontinued

• Sliding scale insulin alone is strongly discouraged and ineffective for glycemic management in both hospitalized and outpatient settings, as it only treats hyperglycemia reactively rather than preventing it 1
• Multiple guidelines explicitly recommend avoiding prolonged sliding scale insulin use, as it fails to provide adequate basal coverage and leads to persistent hyperglycemia 1, 2
• The patient's blood glucose ranging from 150-300 mg/dL demonstrates the inadequacy of sliding scale monotherapy 2

Immediate Treatment Plan: Structured Insulin Regimen

Step 1: Initiate Basal Insulin

• Start basal insulin (glargine, detemir, or degludec) at 10 units daily or 0.1-0.2 units/kg/day, depending on current weight and degree of hyperglycemia 1, 3
• Increase the basal dose by 2-4 units every 3-7 days until fasting blood glucose consistently reaches 80-130 mg/dL 1, 2, 4
• Continue metformin if the patient is on it, as this provides complementary glucose-lowering and reduces total insulin requirements 1, 2

Step 2: Add Prandial Insulin Coverage

• Begin with rapid-acting insulin (aspart, lispro, or glulisine) at the largest meal, starting with 4 units or 10% of the basal insulin dose 1, 2
• Increase prandial insulin by 1-2 units or 10-15% twice weekly based on 2-hour postprandial glucose readings 2, 4
• If A1C remains elevated after optimizing one meal, add prandial insulin before additional meals sequentially 1, 2

Step 3: Maintain Correction Insulin

• Continue using correction (supplemental) insulin with meals to address unexpected hyperglycemia, but never as the sole insulin therapy 1, 2

Special Considerations for This Patient

Addressing Diabetic Complications

• The presence of eye complications and recurrent infections indicates chronic poor glycemic control requiring aggressive treatment intensification 2, 5
• Recurrent infections in diabetes are exacerbated by persistent hyperglycemia and require both antimicrobial therapy and improved glucose control 5
• The HbA1c of 6.5% may be misleadingly low if measured during a period of acute illness or may reflect recent glucose variability rather than sustained control 2

Why Previous 70/30 Insulin Failed

• Premixed insulin (70/30) has both advantages and disadvantages: it provides both basal and prandial coverage but lacks flexibility for dose adjustment 1
• The fixed ratio in premixed insulin cannot be individualized to match this patient's variable carbohydrate intake and activity patterns 1
• Switching to basal-bolus allows independent titration of basal and prandial components 1, 2

Monitoring and Titration Protocol

Blood Glucose Monitoring

• Check fasting glucose daily to guide basal insulin titration 2, 4
• Check pre-meal and 2-hour post-meal glucose to guide prandial insulin adjustments 2, 4
• Monitor for hypoglycemia, especially 2-4 hours after rapid-acting insulin administration 2

Follow-up Schedule

• Reassess glycemic control every 2-3 months with HbA1c measurement 2, 4
• Adjust insulin doses at each visit to avoid therapeutic inertia 4
• If basal insulin exceeds 0.5 units/kg/day without achieving targets, this signals the need for prandial insulin intensification rather than further basal increases 4

Critical Pitfalls to Avoid

• Do not delay insulin intensification while trying additional oral agents, as prolonged severe hyperglycemia increases complication risk 2
• Avoid relying solely on correction insulin without adequate basal coverage, as this approach is ineffective 1, 2
• Do not continue sulfonylureas if moving to complex insulin regimens, as this significantly increases hypoglycemia risk 1, 2
• Never use insulin as a threat or describe it as punishment; frame it as the most effective tool for preventing complications 4

Alternative Considerations

If Adherence to Multiple Daily Injections Is Challenging

• Consider twice-daily premixed insulin as a simpler alternative, though it offers less flexibility than basal-bolus 1, 2

If Cost Is a Barrier

• NPH insulin can be used instead of long-acting analogs for basal coverage, though it carries higher hypoglycemia risk 1
• Regular insulin can substitute for rapid-acting analogs for prandial coverage, dosed 30 minutes before meals 1

Adjunctive Therapy Options

• Consider adding a GLP-1 receptor agonist if the patient can afford it, as this provides additional glucose-lowering with weight loss benefits and reduced insulin requirements 2, 6
• SGLT2 inhibitors should be avoided in hospitalized patients but may be considered for outpatient management once stable 1

Patient Education Requirements

• Comprehensive education on self-monitoring of blood glucose, insulin injection technique, and hypoglycemia recognition and treatment is critically important 1, 2
• Provide written instructions for insulin dose adjustments based on glucose patterns 4
• Supply hypoglycemia treatment supplies (glucose tablets or gel) and ensure the patient understands when to use them 1