What is the initial treatment for a 59-year-old female patient with newly diagnosed type 2 diabetes mellitus (T2DM), presenting with hyperglycemia (glucose level of 416), and taking no current medications, with laboratory tests scheduled for the following day?

Initial Treatment for Newly Diagnosed Type 2 Diabetes with Severe Hyperglycemia

Start metformin 500 mg once or twice daily immediately AND initiate basal insulin (insulin glargine) at 10 units once daily (or 0.2 units/kg given her glucose of 416 mg/dL), then titrate the insulin aggressively by 4 units every 3 days until fasting glucose reaches 80-130 mg/dL. 1

Immediate Medication Initiation

Metformin as Foundation Therapy

• Metformin must be started immediately at 500 mg once or twice daily with food, even when initiating insulin therapy. 1
• Titrate gradually to 1000 mg twice daily (2000 mg total) over 2-4 weeks to minimize gastrointestinal side effects. 1
• Metformin reduces cardiovascular events and death, is inexpensive, and when combined with insulin reduces total insulin requirements and prevents weight gain. 1, 2
• Continue metformin throughout treatment intensification unless contraindicated (eGFR <30 mL/min/1.73 m²). 1

Insulin Therapy for Severe Hyperglycemia

• With a glucose of 416 mg/dL, this patient requires insulin therapy from the outset, not metformin monotherapy alone. 1
• The ADA explicitly recommends initiating insulin therapy (with or without additional agents) in patients with newly diagnosed type 2 diabetes who have blood glucose ≥300 mg/dL. 1
• Start insulin glargine (Lantus) at 10 units once daily OR 0.1-0.2 units/kg body weight, administered at the same time each day. 1, 3
• For this patient with glucose of 416 mg/dL, use the higher end of the dosing range: 0.2 units/kg/day. 1

Aggressive Insulin Titration Protocol

Titration Schedule

• Increase insulin glargine by 4 units every 3 days if fasting glucose remains ≥180 mg/dL. 1, 4
• Increase by 2 units every 3 days if fasting glucose is 140-179 mg/dL. 1, 4
• Target fasting plasma glucose: 80-130 mg/dL. 1, 4
• If hypoglycemia occurs without clear cause, reduce dose by 10-20% immediately. 1, 4

Patient Self-Management

• The patient should check fasting blood glucose every morning during titration. 4, 3
• Equip her with a self-titration algorithm so she can adjust her own insulin dose based on fasting glucose readings. 3
• This approach improves glycemic control and reduces time to target. 3

Critical Threshold: When to Add Prandial Insulin

Recognizing Overbasalization

• When basal insulin exceeds 0.5 units/kg/day (approximately 30 units for a 60 kg patient), stop escalating basal insulin and add prandial insulin instead. 1, 4
• Clinical signals of overbasalization include: basal dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia episodes, and high glucose variability. 4, 3

Adding Prandial Coverage

• Start with 4 units of rapid-acting insulin (lispro, aspart, or glulisine) before the largest meal, OR use 10% of the current basal dose. 1, 4, 3
• Titrate prandial insulin by 1-2 units every 3 days based on 2-hour postprandial glucose readings. 1, 4, 3
• Add prandial insulin to additional meals as needed based on glucose patterns. 1, 4

Laboratory Monitoring

Tomorrow's Labs Should Include

• HbA1c to establish baseline glycemic control. 1
• Comprehensive metabolic panel including creatinine and eGFR to assess kidney function before metformin initiation. 1
• Lipid panel, as cardiovascular risk assessment is essential. 1
• Consider checking vitamin B12 level at baseline, as long-term metformin use can cause deficiency. 1

Follow-up Monitoring

• Recheck HbA1c every 3 months during intensive titration. 4, 3
• Monitor vitamin B12 levels periodically, especially if anemia or peripheral neuropathy develops. 1

Patient Education Essentials

Hypoglycemia Recognition and Treatment

• Teach recognition of hypoglycemia symptoms (shakiness, sweating, confusion, rapid heartbeat). 4, 3
• Treat hypoglycemia immediately with 15 grams of fast-acting carbohydrate (4 glucose tablets, 4 oz juice, or 3-4 hard candies). 4, 3
• Always carry a source of fast-acting carbohydrates. 4, 3

Insulin Administration

• Proper injection technique and site rotation to prevent lipodystrophy. 4, 3
• Insulin storage and handling instructions. 4, 3
• Administer insulin glargine at the same time each day for consistent coverage. 3

Sick Day Management

• Stop metformin if experiencing nausea, vomiting, or dehydration to prevent lactic acidosis. 1
• Continue basal insulin even during illness, but may need dose adjustment. 4, 3

Common Pitfalls to Avoid

Do Not Delay Insulin Initiation

• Never delay insulin therapy in patients with glucose ≥300 mg/dL, as this prolongs hyperglycemia exposure and increases complication risk. 1
• Waiting for metformin monotherapy to work in this setting is inappropriate and dangerous. 1

Do Not Discontinue Metformin When Starting Insulin

• Metformin should be continued when adding or intensifying insulin therapy unless contraindicated. 1, 4
• The combination provides superior glycemic control with reduced insulin requirements and less weight gain compared to insulin alone. 1

Do Not Continue Escalating Basal Insulin Beyond 0.5 units/kg/day

• Continuing to increase basal insulin beyond this threshold without addressing postprandial hyperglycemia leads to overbasalization with increased hypoglycemia risk and suboptimal control. 4, 3
• At this point, add prandial insulin rather than further increasing basal insulin. 1, 4, 3

Do Not Use Sliding Scale Insulin as Monotherapy

• Sliding scale insulin as the sole treatment is explicitly condemned by all major diabetes guidelines. 4, 3
• It treats hyperglycemia reactively rather than preventing it, leading to dangerous glucose fluctuations. 4, 3

Expected Outcomes

Short-Term Goals (3 Months)

• Fasting glucose consistently 80-130 mg/dL. 1, 4
• HbA1c reduction of 2-3% from baseline is achievable with proper basal-bolus therapy. 4
• Most patients can achieve mean blood glucose <140 mg/dL with appropriate insulin intensification. 4

Long-Term Management

• Reassess every 3-6 months once stable to evaluate overall glycemic control and medication regimen. 4, 3
• If HbA1c remains above target after 3-6 months despite achieving fasting glucose goals, add prandial insulin coverage. 1, 4
• Consider adding a GLP-1 receptor agonist to basal insulin to improve glycemic control while minimizing weight gain and hypoglycemia risk. 4, 3