What is the best management plan for a patient with poorly controlled diabetes mellitus (DM), characterized by hyperglycemia and an elevated hemoglobin A1c (HbA1c) level?

Management of Severe Hyperglycemia (HbA1c 14%, Blood Glucose 345 mg/dL)

This patient requires immediate initiation of insulin therapy combined with metformin to rapidly reduce severe hyperglycemia and prevent metabolic decompensation and long-term complications. 1

Immediate Treatment Protocol

Insulin Initiation (Mandatory)

• Start basal insulin immediately at 10 units daily or 0.1-0.2 units/kg/day 1, 2
• With glucose levels >300 mg/dL and HbA1c >10%, insulin therapy is non-negotiable and must be initiated from the outset 1
• Titrate insulin dose by 2 units every 3 days until fasting blood glucose reaches <130 mg/dL 2
• Consider adding mealtime (prandial) insulin at 4 units per meal or 10% of basal dose if postprandial glucose remains >180 mg/dL after basal insulin optimization 1

Concurrent Metformin Therapy (Unless Contraindicated)

• Start metformin 500 mg once or twice daily with meals simultaneously with insulin initiation 1, 2
• Titrate up to 2000 mg daily over 2-4 weeks as tolerated to minimize gastrointestinal side effects 2
• Check renal function before initiating; contraindicated if GFR <30 mL/min 2
• Metformin reduces insulin requirements, limits weight gain, and provides cardiovascular benefits 1, 2

Critical Assessment Points

Rule Out Diabetic Ketoacidosis

• Check for symptoms of profound insulin deficiency: weight loss, polyuria, polydipsia 1
• Test urine or blood for ketones immediately 3
• If ketosis is present with vomiting, this represents diabetic ketoacidosis requiring immediate hospitalization 3

Determine Diabetes Type

• Consider unrecognized type 1 diabetes if patient presents with catabolic features (weight loss) and ketonuria 1
• This distinction is critical as it affects long-term management strategy

Monitoring Strategy

Intensive Glucose Monitoring

• Self-monitor blood glucose at least 3 times daily (fasting and pre-meals) until glucose stabilizes below 200 mg/dL 1
• Continue frequent monitoring to guide insulin dose adjustments and prevent hypoglycemia 3
• Recheck HbA1c after 3 months to assess treatment effectiveness 2

Hypoglycemia Prevention

• Educate patient on hypoglycemia recognition and treatment with 15-20 grams of rapid-acting glucose 3
• Prescribe glucagon and train family members on administration 3
• If hypoglycemia occurs, reduce corresponding insulin dose by 10-20% 4

Target Goals

Glycemic Targets

• Target HbA1c <7% for most patients to reduce microvascular and macrovascular complications 3
• Fasting plasma glucose target: <130 mg/dL 2
• Postprandial glucose target: <180 mg/dL 4
• More stringent targets (<6.5%) may be appropriate if achievable without hypoglycemia in younger patients with short disease duration 3

Transition Strategy After Stabilization

De-escalation Plan

• Once glucose levels stabilize and HbA1c approaches target, consider tapering insulin partially or entirely over 2-6 weeks 1, 2
• Decrease insulin dose by 10-30% every few days while monitoring glucose closely 2
• Transition to combination therapy with metformin plus additional agents (GLP-1 receptor agonist or SGLT2 inhibitor preferred for cardiovascular benefits) 1, 4

Comprehensive Diabetes Management

Lifestyle Interventions (Concurrent with Pharmacotherapy)

• Initiate diabetes self-management education immediately 3
• Refer to registered dietitian for individualized medical nutrition therapy 3
• Prescribe at least 150 minutes of moderate-intensity aerobic activity per week plus resistance training twice weekly 3
• Target at least 5% body weight loss if overweight or obese 3

Cardiovascular Risk Reduction

• Address blood pressure control, lipid management, and smoking cessation concurrently 1
• These interventions are equally important as glycemic control for reducing mortality and morbidity 1

Critical Pitfalls to Avoid

Do Not Delay Insulin

• Never start with oral monotherapy alone when glucose is consistently >300 mg/dL or HbA1c ≥10% 1
• Delaying insulin in severe hyperglycemia increases risk of metabolic decompensation and accelerates complications 1
• Oral agents alone have low probability of achieving near-normal targets at this severity 1

Do Not Overlook Type 1 Diabetes

• Check for ketonuria in all patients presenting with severe hyperglycemia and weight loss 1
• Misdiagnosing type 1 diabetes as type 2 can lead to life-threatening diabetic ketoacidosis 1

Ensure Proper Patient Education

• Verify proper insulin injection technique and storage before discharge 1
• Confirm patient understands hypoglycemia recognition and treatment 3
• Schedule close follow-up within 1-2 weeks to assess response and adjust doses 3

Medication Reconciliation

• If patient is on sulfonylureas (like glipizide), strongly consider discontinuing once insulin is established to reduce hypoglycemia risk 2