What are the recommendations for an adult patient with type 2 diabetes mellitus (T2DM), weighing 87 kg, Body Mass Index (BMI) of 33, and Hemoglobin A1c (HbA1c) of 10.4%, who stopped taking glipizide (sulfonylurea), an unspecified medication, and metformin (biguanide) for 1 week?

Discharge Recommendations for Type 2 Diabetes with A1c 10.4%

Immediate Medication Restart and Intensification

This patient requires immediate resumption of diabetes medications with significant treatment intensification given the severely elevated A1c of 10.4%, which is well above any recommended target and indicates urgent need for aggressive glycemic control. 1

Primary Recommendation: Initiate Insulin Therapy

• Start basal insulin immediately given the A1c >10% and symptomatic hyperglycemia after medication discontinuation 1
• Begin with basal insulin (long-acting insulin analog such as glargine or detemir) at 10 units daily or 0.1-0.2 U/kg (approximately 9-17 units for this 87 kg patient) 1
• Administer in the morning rather than bedtime to reduce nocturnal hypoglycemia risk 2
• Titrate by 2 units every 3-7 days based on fasting glucose, targeting 90-130 mg/dL 2

Restart and Optimize Oral Medications

• Resume metformin 500 mg XL immediately and increase to at least 1500-2000 mg daily (if tolerated and renal function permits) as it should remain part of the regimen unless contraindicated 1
• Do NOT restart glipizide - sulfonylureas cause hypoglycemia and weight gain, which are particularly problematic in this patient with BMI 33 1
• The unspecified 2.5 mg weekly medication is likely a GLP-1 receptor agonist (possibly dulaglutide or semaglutide) - restart this medication as GLP-1 RAs are preferred for patients with BMI >30 kg/m² 1

Add SGLT2 Inhibitor

• Add an SGLT2 inhibitor (empagliflozin 10 mg, dapagliflozin 10 mg, or canagliflozin 100 mg daily) as second-line therapy given the BMI of 33 kg/m² 1
• SGLT2 inhibitors reduce A1c by 0.5-1.0%, promote 1.5-3.5 kg weight loss, and provide cardiovascular and renal protection 1
• Monitor for genitourinary infections and ensure adequate hydration 1
• Check renal function within 2-4 weeks of initiation 3

Glycemic Target

• Target A1c <7.5-8.0% for this patient given age, BMI, and current severe hyperglycemia 1, 3
• More stringent targets (<7%) may be appropriate once stable control is achieved, but initial focus should be on substantial A1c reduction without excessive hypoglycemia risk 1

Monitoring Plan

• Check fasting glucose daily during insulin titration phase 2
• Recheck A1c in 3 months to assess treatment response 1, 3
• Monitor renal function and electrolytes within 2-4 weeks after starting SGLT2 inhibitor 3
• Weekly follow-up (phone or in-person) during first month to adjust insulin doses 2

Specific Discharge Regimen

Medications to prescribe:

1. Basal insulin (glargine or detemir) 10-15 units subcutaneously every morning
2. Metformin XL 1000 mg twice daily (or 2000 mg once daily)
3. GLP-1 receptor agonist (resume previous 2.5 mg weekly medication)
4. SGLT2 inhibitor (empagliflozin 10 mg or dapagliflozin 10 mg daily)

Do NOT prescribe:

• Glipizide or any sulfonylurea 1

Critical Pitfalls to Avoid

• Do not use sliding scale insulin alone in outpatient management - it is ineffective and increases hypoglycemia risk 2
• Do not delay insulin initiation - with A1c >10%, oral agents alone will be insufficient 1
• Do not restart glipizide - the hypoglycemia and weight gain risks outweigh benefits when better alternatives exist 1
• Do not administer basal insulin at bedtime initially - morning dosing reduces nocturnal hypoglycemia risk in this population 2
• Verify renal function before metformin dosing - avoid if eGFR <30 mL/min/1.73 m², reduce dose if 30-60 mL/min/1.73 m² 2

Patient Education Requirements

• Insulin injection technique and storage 1
• Recognition and treatment of hypoglycemia (glucose <70 mg/dL: consume 15g fast-acting carbohydrate) 2
• Daily fasting glucose monitoring and log keeping 2
• Signs of diabetic ketoacidosis (nausea, vomiting, abdominal pain, fruity breath) given SGLT2 inhibitor use 1
• Genital hygiene to prevent infections with SGLT2 inhibitor 1
• Importance of medication adherence - emphasize consequences of stopping medications 1

Follow-up Timeline

• Week 1-2: Phone contact to review glucose logs and adjust insulin dose
• Week 2-4: Check renal function and electrolytes (for SGLT2 inhibitor monitoring) 3
• Month 1: Office visit to assess glucose control, adjust medications, review technique
• Month 3: Recheck A1c, comprehensive diabetes assessment 1, 3

Rationale for Aggressive Approach

This patient's A1c of 10.4% represents severe hyperglycemia that requires immediate intensive intervention 1. The combination of basal insulin, metformin, GLP-1 RA, and SGLT2 inhibitor addresses multiple pathophysiologic defects: insulin deficiency, insulin resistance, incretin deficiency, and excess renal glucose reabsorption 1. This regimen minimizes hypoglycemia risk while maximizing A1c reduction potential (expected 3-4% reduction) and promoting weight loss rather than gain 1.