What is the best course of treatment for a 56-year-old female with a history of essential hypertension, depression, gastroesophageal reflux disease (GERD), type 2 diabetes mellitus (T2DM) with diabetic neuropathy and severe nonproliferative diabetic retinopathy, mixed hyperlipidemia, and vitamin D deficiency, presenting with poorly controlled diabetes, dehydration, and elevated glucose readings, who has stopped taking a previously prescribed medication due to loss of insurance coverage?

Immediate Insulin Intensification with Hydration and Medication Optimization

This patient requires immediate insulin dose optimization, aggressive hydration, and urgent reinitiation of metformin to prevent progression to hyperglycemic crisis. With an A1C of 9.6%, glucose readings of 160-240 mg/dL, signs of dehydration (concentrated urine, low CO2), and a 3-month gap in metformin therapy due to insurance loss, she is at high risk for diabetic ketoacidosis given her prior DKA history 1, 2.

Immediate Actions Required

Insulin Regimen Adjustment

• Calculate and increase her total daily insulin dose immediately 2. Her current regimen (Humalog + Lantus) is clearly insufficient given persistent hyperglycemia and elevated A1C 3.
• Increase basal insulin (Lantus) by 10-20% and adjust prandial insulin (Humalog) based on carbohydrate intake and correction factors 2.
• Target glucose range of 140-180 mg/dL initially, then tighten to 80-130 mg/dL fasting once stable 3, 2.
• Critical pitfall: Do not delay insulin intensification in patients with A1C >9.5% and symptomatic hyperglycemia (increased thirst, urination) 2.

Hydration Protocol

• Aggressive oral hydration is essential given the concentrated urine and low CO2 suggesting dehydration 1.
• Instruct patient to drink 8-10 glasses of water daily and monitor for symptoms of severe dehydration (altered mental status, severe weakness) 1.
• If unable to maintain oral hydration or symptoms worsen, immediate ED evaluation is required 1.

Metformin Reinitiation

• Restart metformin 1000 mg twice daily immediately 3. Metformin remains first-line therapy for type 2 diabetes due to high efficacy, low hypoglycemia risk, and cardiovascular benefits 3.
• Verify kidney function is adequate (eGFR >30 mL/min/1.73m²) before restarting—her labs show normal kidney function 3.
• Counsel patient to hold metformin during acute illness, vomiting, or dehydration to prevent lactic acidosis 3.
• Address cost barriers: provide samples, manufacturer assistance programs, or switch to generic formulations 3.

Monitoring and Safety Measures

Glucose Monitoring

• Implement structured blood glucose monitoring: fasting, pre-meals, and 2-hours post-meals at least 4 times daily until control improves 3, 2.
• Given her prior use of Libre CGM, explore patient assistance programs or lower-cost alternatives (FreeStyle Libre 14-day system, Dexcom G6) as CGM significantly improves outcomes in insulin-treated patients 3.
• Alert thresholds: Contact provider immediately for glucose <70 mg/dL, or >300 mg/dL on two consecutive days 3, 1.

Hypoglycemia Prevention

• Educate on hypoglycemia recognition and treatment before any insulin dose increase 2, 4.
• Provide glucagon emergency kit and train family member on administration 4.
• Adjust insulin doses if glucose falls below 100 mg/dL; modify when <70 mg/dL 2, 4.

Addressing Diabetic Complications

Retinopathy Considerations

• Her severe nonproliferative diabetic retinopathy requires urgent ophthalmology follow-up within 1-2 weeks 3.
• With severe NPDR, vigorous aerobic or resistance exercise is contraindicated due to risk of vitreous hemorrhage or retinal detachment 3.
• Recommend moderate-intensity walking only, avoiding heavy lifting or straining 3.
• Optimizing glycemic control is critical to slow retinopathy progression 3.

Gastroparesis Assessment

• Her "stomach contractions" and occasional diarrhea may represent diabetic autonomic neuropathy with gastroparesis 3.
• This complicates insulin timing: if gastroparesis confirmed, consider switching to rapid-acting insulin after meals rather than before to match unpredictable carbohydrate absorption 3.
• Refer to gastroenterology if symptoms persist for gastric emptying study 3.

Neuropathy Management

• Continue current diabetic neuropathy treatment 3.
• Achieving near-normoglycemia can prevent progression but will not reverse existing neuronal loss 3.

Psychosocial and Adherence Support

Depression and Social Stressors

• Her depression (fluoxetine 60 mg) and significant social stressors (relative's dementia, vision loss, insurance loss) directly impact diabetes self-management 3.
• Screen for diabetes distress and treatment adherence barriers at every visit 3.
• Consider referral to diabetes educator or social work for assistance with insurance coverage, medication access, and caregiver support 5.

Medication Adherence

• The 3-month gap in metformin is the primary driver of her poor control 6, 7.
• Address insurance barriers immediately: apply for patient assistance programs, explore state Medicaid expansion, or use $4 generic programs at major pharmacies 3.
• Improved control depends largely on patient self-care behaviors including medication adherence, meal planning, and glucose monitoring 6.

Follow-Up Plan

Short-Term (1 Week)

• Schedule follow-up within 1 week to assess response to insulin adjustment and metformin reinitiation 2.
• Review glucose logs and adjust insulin doses based on patterns 2.
• Verify metformin prescription filled and patient taking as directed 1.

Medium-Term (1-3 Months)

• Recheck A1C in 3 months to assess durability of glycemic control 2.
• Annual diabetic kidney disease screening with urine albumin-creatinine ratio and eGFR 3.
• Annual comprehensive foot examination with 10-g monofilament testing 3.
• Ensure annual comprehensive eye examination by ophthalmologist 3.

Long-Term Considerations

• Once A1C <8% and stable, consider adding SGLT2 inhibitor or GLP-1 receptor agonist for additional cardiovascular and renal protection, particularly given her multiple risk factors 3.
• However, SGLT2 inhibitors should be used with caution given her dehydration risk and must be held during acute illness 3.
• Continue atorvastatin 20 mg for cardiovascular risk reduction 3.

Critical Warnings

This patient is at high risk for recurrent DKA given her history and current poor control 1, 7. Educate that persistent glucose >300 mg/dL, nausea, vomiting, or abdominal pain requires immediate ED evaluation 1. The combination of medication non-adherence (metformin gap), inadequate insulin dosing, and dehydration creates a perfect storm for hyperglycemic crisis 1, 7. Sentinel ED visits for hyperglycemia often precede admission for DKA/HHS within 14 days 7.