What is the treatment plan for a type 1 diabetic patient with an A1c (glycated hemoglobin) level greater than 15?

Treatment Plan for Type 1 Diabetes with A1C >15%

Immediate Insulin Intensification

For a type 1 diabetic patient with A1C >15%, immediate aggressive insulin therapy using multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII) is required, with total daily insulin doses starting at 0.5-1.0 units/kg/day split approximately 50% basal and 50% prandial insulin. 1, 2

Initial Insulin Regimen Structure

• Start with 0.5-1.0 units/kg/day total daily insulin dose, with higher doses (closer to 1.0 units/kg/day) appropriate given the severe hyperglycemia 2, 3
• Distribute as 50% basal insulin (long-acting analog such as insulin glargine) and 50% prandial insulin (rapid-acting analog such as insulin aspart) 2, 3, 4
• Administer basal insulin once daily at bedtime (insulin glargine may require twice-daily dosing in some patients) 3
• Administer rapid-acting insulin analogs immediately before each meal rather than regular human insulin to minimize hypoglycemia risk 5, 2

Specific Insulin Adjustment Protocol

• Increase basal insulin by 2-4 units every 3-7 days until fasting blood glucose reaches target levels (60-130 mg/dL) 1
• Increase prandial insulin doses to at least 10% of total daily basal dose, with further adjustments based on postprandial glucose readings 1
• For patients with A1C >10%, more aggressive insulin therapy is warranted to reduce risk of diabetic ketoacidosis 1

Monitoring Strategy

Glucose Monitoring Requirements

• Implement continuous glucose monitoring (CGM) or multiple daily capillary blood glucose measurements (minimum 4-6 times daily before meals and at bedtime) 5, 6
• Schedule frequent clinic visits every 1-2 weeks initially to check blood glucose levels and adjust insulin doses 1
• Consider point-of-care A1C testing at each visit to allow for more timely treatment changes 1

Common Pitfall: Patients may resist frequent monitoring, but with A1C >15%, this represents severe uncontrolled diabetes requiring intensive surveillance to prevent acute complications including diabetic ketoacidosis 1

Patient Education Components

Essential Skills Training

• Educate on matching prandial insulin doses to carbohydrate intake using carbohydrate counting as the foundation 5, 2
• Teach recognition and response to symptoms of hypoglycemia and hyperglycemia, even without a meter 1
• Instruct patient to carry fast-acting carbohydrates (at least 15g) at all times to treat hypoglycemia 1
• Prescribe glucagon for all patients, with education for family members and caregivers on administration 2

Correction Dose Education

• Teach correction dose calculation based on insulin sensitivity factor and current blood glucose relative to target 5, 2
• Educate on sick-day management given the high risk of diabetic ketoacidosis with severe hyperglycemia 6

Addressing Barriers to Care

Financial and Access Considerations

• Investigate patient assistance programs from insulin manufacturers for uninsured or underinsured patients 1
• Consider less expensive insulin options if cost is a barrier (e.g., human insulins available at lower cost from certain pharmacies, though analogs are preferred) 1
• Connect patient with social services to help obtain insurance coverage 1

Advanced Therapy Considerations

Technology-Enhanced Management

• Consider automated insulin delivery systems or sensor-augmented pump therapy once initial stabilization is achieved, as these provide superior glycemic control with reduced hypoglycemia risk 5, 2
• For patients with frequent nocturnal hypoglycemia or hypoglycemia unawareness, sensor-augmented low glucose threshold suspend pump should be considered 5

Important Note: While continuous subcutaneous insulin infusion (pump therapy) offers advantages, initial management with MDI is appropriate and effective, with transition to pump therapy considered after metabolic stabilization 5

Screening for Comorbidities

• Screen for thyroid dysfunction, vitamin B12 deficiency, and celiac disease based on signs and symptoms, as these autoimmune conditions are more frequent in type 1 diabetes 5
• Assess for diabetic complications given the prolonged poor glycemic control indicated by A1C >15% 1

Adjunctive Therapy Limitations

Pramlintide is the only FDA-approved adjunctive therapy for type 1 diabetes, but it requires concurrent reduction of prandial insulin dosing to reduce hypoglycemia risk and is only indicated in adults 5, 7

• Metformin may reduce insulin requirements but does not significantly improve A1C in type 1 diabetes 5, 7
• SGLT2 inhibitors and GLP-1 receptor agonists are NOT FDA-approved for type 1 diabetes and carry increased risk of diabetic ketoacidosis 5, 7

Target Goals

• Aim for A1C <7% for most nonpregnant adults, though initial goal should be gradual reduction to avoid complications from rapid glucose normalization 1, 6
• Target premeal glucose 60-130 mg/dL and postprandial glucose <180 mg/dL 5

Critical Caveat: With A1C >15%, expect gradual improvement over 3-6 months rather than immediate normalization. Rapid correction can paradoxically worsen retinopathy and neuropathy symptoms 1