What is the optimal treatment plan for a 51-year-old male with uncontrolled type 2 diabetes mellitus (T2DM), diabetic neuropathy, and dyslipidemia, currently taking Insulin Glargine (insulin glargine), Metformin (metformin), Pregabalin (pregabalin), and Atorvastatin (atorvastatin), with symptoms of numbness, paresthesia, and dizziness, and lab results showing hyperglycemia (HbA1c 9.70%) and impaired renal function?

Optimal Treatment Plan for Uncontrolled T2DM with Diabetic Neuropathy

Continue Current Insulin and Metformin Regimen with Aggressive Pregabalin Dose Escalation

The current treatment plan is fundamentally sound but requires immediate pregabalin dose escalation to achieve therapeutic benefit for neuropathic pain, as the 75 mg dose is subtherapeutic. 1, 2 The patient's glycemic control is improving (HbA1c 9.7% initially, with recent fasting glucose readings 96-122 mg/dL), and the combination of insulin glargine 14 units with metformin 1000 mg BID should be maintained while addressing the inadequate neuropathy management. 3

Immediate Medication Adjustments

Pregabalin Dose Escalation (Priority Action)

• Increase pregabalin to 150 mg at bedtime immediately for 1 week, as the current 75 mg dose is well below the effective therapeutic range of 300-600 mg/day. 1, 2, 4
• If tolerated after 1 week, advance to 150 mg twice daily (morning and bedtime) to reach 300 mg/day total. 2, 4
• The patient's dizziness complaint is a common side effect that typically improves with continued use and taking the medication before sleep, not a reason to maintain subtherapeutic dosing. 4
• Maximum effective dose is 300-600 mg/day divided into 2-3 doses; most patients require at least 300 mg/day for adequate pain control. 3, 1, 5

Glycemic Management (Continue Current Approach)

• Maintain insulin glargine 14 units at bedtime - the fasting glucose readings (96-122 mg/dL) demonstrate appropriate basal insulin coverage. 3
• Continue metformin 1000 mg BID - this is the preferred first-line agent and should remain part of the regimen. 3
• The patient's renal function is normal (creatinine 83 μmol/L, eGFR >60), so metformin is safe and there is no basis for the patient's fear of renal side effects. 3, 6

Lipid Management (Continue Current Statin)

• Continue atorvastatin 40 mg at bedtime - this is appropriate high-intensity statin therapy for a 51-year-old diabetic patient with LDL 102.87 mg/dL (target <100 mg/dL, ideally <70 mg/dL for high-risk patients). 3
• The low HDL (31 mg/dL, target >40 mg/dL for men) will improve with better glycemic control and continued lifestyle modifications. 3

Addressing Postprandial Hyperglycemia

The patient's postprandial glucose readings show inadequate mealtime coverage (after lunch 189 mg/dL, after dinner 174 mg/dL initially). 2

Two options for addressing postprandial hyperglycemia:

1. Add rapid-acting insulin at the largest meal (typically lunch based on the glucose log showing after-lunch reading of 189 mg/dL). Start with 4 units of rapid-acting insulin before lunch, titrate by 1-2 units every 3 days based on 2-hour postprandial readings (target <180 mg/dL). 3

2. Increase metformin to 1500-2000 mg/day (split as 1000 mg morning, 500-1000 mg evening) if gastrointestinal tolerance permits, as this may improve postprandial control without adding injection burden. 3

I recommend option 1 (adding mealtime insulin) given the HbA1c of 9.7% indicates the need for more aggressive therapy. 3

Monitoring Parameters

Glucose Monitoring

• Fasting glucose daily to guide basal insulin titration (target 80-130 mg/dL). 3, 2
• 2-hour postprandial glucose after lunch 3-4 times weekly to assess mealtime coverage (target <180 mg/dL). 3, 2
• Repeat HbA1c in 3 months to assess overall control (target <7.0%). 3

Neuropathy Assessment

• Quantify pain using 0-10 numeric rating scale at each visit - the patient reported improvement from 5/10 to 0/10 for paresthesias but persistent numbness. 2
• Perform 10-g monofilament testing at each visit to detect loss of protective sensation and prevent foot ulceration. 3, 1, 2
• Assess for new symptoms: worsening numbness, balance problems, or foot injuries. 1, 2

Pregabalin Side Effect Monitoring

• Monitor for dizziness, somnolence, peripheral edema, and weight gain - these are the most common adverse effects. 4
• Assess for mood changes as pregabalin carries a warning for suicidal behavior and ideation. 4

Critical Pitfalls to Avoid

Metformin Safety

• The patient's fear of renal side effects from metformin is unfounded with normal renal function (eGFR >60). 3, 6
• Metformin is contraindicated only when eGFR <30 mL/min/1.73 m² and should not be initiated when eGFR 30-45 mL/min/1.73 m². 6
• Educate the patient that metformin is safe with his current renal function and is essential for cardiovascular protection. 3, 6

Pregabalin Dosing Error

• The most common error is maintaining subtherapeutic pregabalin doses due to side effect concerns. 1, 2
• Dizziness typically improves with continued use and bedtime dosing; it should not prevent dose escalation to therapeutic levels. 4
• Failure to achieve therapeutic dosing (300-600 mg/day) results in inadequate pain control and unnecessary suffering. 3, 1, 5

Glycemic Control Priority

• Tight glycemic control (HbA1c 6-7%) is the only intervention proven to delay diabetic neuropathy progression, though it will not reverse existing nerve damage. 3, 1, 2
• The patient's improving glucose control (fasting readings now 96-122 mg/dL) should be maintained and further optimized. 1, 2

Alternative Considerations if Current Plan Fails

If Pregabalin Intolerance Develops

• Switch to duloxetine 60 mg daily, another FDA-approved first-line agent for diabetic peripheral neuropathy. 3, 2, 5
• Duloxetine should be avoided in patients with hepatic disease, which this patient does not have (ALT 22, AST 27). 2

If Monotherapy Inadequate for Pain

• Consider combination therapy with pregabalin plus duloxetine or tricyclic antidepressant (amitriptyline 25-75 mg at bedtime). 2, 5
• Avoid tricyclic antidepressants if cardiovascular disease, glaucoma, or orthostatic hypotension develops. 2

If Pain Remains Refractory

• Refer to pain specialist for consideration of spinal cord stimulation, which recently received FDA approval for diabetic neuropathy. 2

Lifestyle Reinforcement

• Continue current dietary modifications (fish and vegetables) and physical activity (feeding chickens) - these are contributing to improved glycemic control. 3
• Target weight loss of at least 5% of body weight (current 84 kg, target <80 kg) to improve insulin sensitivity and neuropathy symptoms. 3
• Emphasize daily foot inspection given the presence of diabetic neuropathy and risk for foot ulceration. 3