What are the discharge recommendations for a 42-year-old obese male with type 2 diabetes, an A1C of 10.4, and blood glucose levels ranging from 200-250 mg/dL, on Lantus (Insulin Glargine) 10 units daily with normal renal function?

Discharge Recommendations for Type 2 Diabetes with Inadequate Glycemic Control

Immediate Insulin Regimen Adjustment

This patient requires aggressive insulin intensification with a basal-bolus regimen at discharge, not continuation of basal insulin alone. Blood glucose levels consistently in the 200-250 mg/dL range with an A1C of 10.4% indicate both inadequate basal coverage and significant postprandial hyperglycemia requiring mealtime insulin 1.

Recommended Discharge Insulin Regimen

Increase Lantus to 20 units once daily at bedtime and add rapid-acting insulin 4-6 units before each of the three largest meals 1. For this 87 kg patient:

• Basal insulin (Lantus): Increase from 10 units to 20 units once daily at bedtime, representing approximately 0.23 units/kg/day 1
• Prandial insulin: Start rapid-acting insulin analog (lispro, aspart, or glulisine) at 4-6 units before breakfast, lunch, and dinner 1
• This provides a total daily dose of approximately 38-48 units (0.44-0.55 units/kg/day), appropriate for an A1C >10% 1

The current regimen of Lantus 10 units alone is grossly inadequate—blood glucose in the 200s mg/dL reflects both insufficient basal coverage AND postprandial excursions that require mealtime insulin 1.

Titration Instructions for Patient

Basal Insulin Titration

• Increase Lantus by 4 units every 3 days if fasting glucose remains ≥180 mg/dL 1
• Increase Lantus by 2 units every 3 days if fasting glucose is 140-179 mg/dL 1
• Target fasting glucose: 80-130 mg/dL 2, 1
• If hypoglycemia occurs (glucose <70 mg/dL), reduce Lantus dose by 10-20% immediately 1

Prandial Insulin Titration

• Increase prandial insulin by 1-2 units every 3 days if 2-hour postprandial glucose consistently exceeds 180 mg/dL 1
• Target postprandial glucose: <180 mg/dL 2
• Adjust each meal's insulin dose independently based on glucose readings 2 hours after that specific meal 1

Critical Threshold Monitoring

When Lantus approaches 0.5-1.0 units/kg/day (44-87 units for this patient) without achieving targets, focus on intensifying prandial insulin rather than continuing to escalate basal insulin alone 1. Signs of "overbasalization" include bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, and high glucose variability 1.

Foundation Oral Therapy

Continue metformin at maximum tolerated dose (up to 2000-2550 mg daily) unless contraindicated 1. The combination of metformin with basal-bolus insulin provides superior glycemic control with reduced insulin requirements and less weight gain compared to insulin alone 1. Metformin should never be discontinued when intensifying insulin therapy 1.

Patient Education Requirements

Provide comprehensive education on 2:

• Insulin injection technique and site rotation to prevent lipohypertrophy 1
• Self-monitoring of blood glucose: Check fasting glucose daily and 2-hour postprandial glucose to guide insulin adjustments 1
• Hypoglycemia recognition and treatment: Treat any glucose <70 mg/dL immediately with 15 grams of fast-acting carbohydrate, recheck in 15 minutes, and repeat if needed 1
• Sick day management: Never stop basal insulin even with poor oral intake; contact provider for dose adjustments 2
• Insulin storage and handling: Store unopened vials/pens in refrigerator; opened insulin can be kept at room temperature for 28 days 1

Monitoring and Follow-Up

• Schedule follow-up appointment within 1-2 weeks given the significant medication changes and suboptimal glucose control 2
• Daily fasting blood glucose monitoring is essential during titration 1
• Check A1C in 3 months to assess overall glycemic control; expect A1C reduction of 2-3% from baseline with appropriate basal-bolus therapy 1
• Provide clear written instructions for insulin titration and glucose targets 2

Medication Reconciliation

• Prescriptions for Lantus and rapid-acting insulin should be filled and reviewed before discharge 2
• Ensure patient has adequate supply of insulin syringes or pen needles, blood glucose meter, and test strips 2
• Verify insurance coverage for prescribed insulins; consider cost if patient has financial constraints 2

Critical Pitfalls to Avoid

Never discharge this patient on basal insulin alone with blood glucose consistently 200-250 mg/dL 1. Continuing to escalate Lantus without addressing postprandial hyperglycemia leads to overbasalization with increased hypoglycemia risk and suboptimal control 1. Never use sliding scale insulin as monotherapy—it is explicitly condemned by all major diabetes guidelines and results in dangerous glucose fluctuations 1. Never discontinue metformin when intensifying insulin unless contraindicated, as this leads to higher insulin requirements and more weight gain 1.

Expected Outcomes

With appropriate basal-bolus therapy at weight-based dosing, this patient can expect mean blood glucose <140 mg/dL and A1C reduction to approximately 7-8% over 3-6 months 1. The combination of basal-bolus insulin with metformin provides superior control compared to insulin alone 1.