What is the best approach to manage a patient with uncontrolled diabetes mellitus (DM)?

Management of Uncontrolled Diabetes

For patients with uncontrolled diabetes, immediately intensify therapy by adding a second agent if on monotherapy, or adding basal insulin if already on dual therapy, while simultaneously addressing lifestyle factors and barriers to adherence. 1

Immediate Assessment and Triage

Determine severity of hyperglycemia:

• If HbA1c ≥10% (≥86 mmol/mol) or random glucose >300-350 mg/dL with symptoms: insulin therapy is essential and should be initiated immediately 1, 2
• If HbA1c 7.5-10%: add second or third agent depending on current regimen 1, 2
• Check for acute complications requiring urgent intervention (DKA, HHS) 1

Identify barriers to control:

• Medication non-adherence, cost issues, or access problems 1
• Language, numeracy, or cultural barriers 1
• Depression, diabetes-related distress, or competing family demands 1
• Inadequate diabetes self-management education 1

Pharmacologic Intensification Strategy

For Type 2 Diabetes Patients

If not on metformin: Start metformin immediately (if GFR >30-45 mL/min, with dose reduction at lower GFR) 1

If on metformin monotherapy: Add a second agent within 3 months if HbA1c target not met 1. Choose from:

• Sulfonylureas (low cost, but hypoglycemia risk) 1
• SGLT2 inhibitors (cardiovascular benefits) 1
• GLP-1 agonists (weight loss, cardiovascular benefits) 1
• DPP-4 inhibitors (weight neutral) 1
• Thiazolidinediones (avoid if heart failure) 1
• Basal insulin (most effective for severe hyperglycemia) 1

If on dual therapy and still uncontrolled: Add basal insulin or GLP-1 agonist 1

Insulin initiation protocol for Type 2 diabetes:

• Start with basal insulin (NPH, glargine, or detemir) 1, 2
• Initial dose: 0.1-0.2 units/kg/day or 10 units daily 1
• Titrate based on fasting plasma glucose every 2-3 days 2
• If basal insulin alone insufficient, add rapid-acting insulin at largest meal, then expand to other meals as needed 1, 2
• Continue metformin when adding insulin to reduce weight gain and insulin requirements 2

For Type 1 Diabetes Patients

All patients require intensive insulin therapy:

• Multiple daily injections (≥3 injections/day) or continuous subcutaneous insulin infusion 1
• Use insulin analogues rather than regular insulin to reduce hypoglycemia risk 1
• Educate on carbohydrate counting and matching prandial insulin to intake 1
• Consider continuous glucose monitoring to reduce severe hypoglycemia 1

Lifestyle and Behavioral Interventions

Nutrition therapy (mandatory for all patients):

• Refer to registered dietitian for individualized medical nutrition therapy 1, 3
• Target ≥5% weight loss if overweight/obese through 500-750 kcal/day deficit 3, 4
• No single ideal macronutrient distribution; individualize based on patient preferences and metabolic goals 3, 4

Physical activity prescription:

• 150 minutes/week of moderate-intensity aerobic activity 1, 3
• Resistance training at least twice weekly 1, 3
• Reduce sedentary time 1

Diabetes self-management education:

• Enroll immediately in structured diabetes self-management education and support program 1, 3
• Focus on glucose monitoring technique, medication administration, hypoglycemia recognition/treatment, and sick-day management 3, 5

Monitoring and Follow-Up

Glucose monitoring frequency:

• Increase blood glucose monitoring during any regimen change 1, 5
• Use fasting glucose to titrate basal insulin 2
• Use both fasting and postprandial glucose to titrate mealtime insulin 2
• HbA1c testing every 3 months until at goal, then every 3-6 months 3, 4

Follow-up schedule:

• Weekly contact (phone or in-person) during insulin titration 2
• Every 2-4 weeks until glycemic targets achieved 1
• Reassess regimen if targets not met within 3 months 1

Team-Based Care Approach

Engage multidisciplinary team:

• Physician, nurse practitioner, or physician assistant for medication management 3, 4
• Certified diabetes educator for self-management training 1, 3
• Pharmacist for medication reconciliation and adherence support 3, 4
• Registered dietitian for nutrition therapy 1, 3
• Mental health professional if depression or diabetes distress identified 1, 3
• Medical social worker for insurance/access issues 1

Cardiovascular Risk Factor Management

Blood pressure control:

• Target <140/90 mmHg (or <130/80 mmHg if tolerated) 3, 4
• Initiate ACE inhibitor or ARB (not both) 3

Lipid management:

• Start statin therapy if age ≥40 years 3
• Intensity based on cardiovascular risk profile 3

Common Pitfalls to Avoid

Clinical inertia: The most common error is failing to intensify therapy promptly when targets are not met 1. Do not wait beyond 3 months to add agents 1.

Overly aggressive targets in high-risk patients: Avoid near-normal HbA1c targets in patients with hypoglycemia unawareness, advanced complications, or limited life expectancy 1. Severe or frequent hypoglycemia mandates regimen modification 1.

Abrupt discontinuation of oral agents: When starting insulin, continue metformin and other oral agents unless contraindicated 2. Abrupt discontinuation risks rebound hyperglycemia 2.

Ignoring psychosocial barriers: Address depression, diabetes distress, health literacy, and financial constraints that impede adherence 1. These factors often explain apparent "treatment failure" 1.

Inadequate patient education: Patients cannot succeed without understanding glucose monitoring, medication administration, hypoglycemia recognition (15-20g rapid-acting glucose for treatment), and sick-day management 3, 5.