Can a 72‑year‑old man with type 2 diabetes mellitus and persistent severe hyperglycemia (>300 mg/dL) despite basal insulin and sliding‑scale therapy, recent right cerebellar infarct, paroxysmal atrial fibrillation on rivaroxaban, hypertension, coronary artery disease, mixed hyperlipidemia, mild anemia, insomnia, and normal renal function be safely discharged home with home‑health services, and what is the appropriate insulin and medication regimen for discharge?

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Last updated: February 6, 2026 • View editorial policy

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Discharge Planning for Elderly Patient with Severe Uncontrolled Type 2 Diabetes

Direct Recommendation

This patient should NOT be discharged home at this time with the current level of uncontrolled hyperglycemia (glucose values 400-464 mg/dL) and requires either continued facility-based care with aggressive insulin titration or discharge on a basal-bolus insulin regimen with very close outpatient follow-up within 1 week, not 1 month. 1

Critical Safety Concerns That Must Be Addressed Before Discharge

Severe Persistent Hyperglycemia

  • The patient demonstrates extreme hyperglycemia with values reaching 461-464 mg/dL despite insulin glargine 30 units BID plus sliding scale aspart and sitagliptin. 1
  • This degree of hyperglycemia in an elderly post-stroke patient on anticoagulation substantially increases risks of infection, impaired wound healing, dehydration, and potential hyperosmolar state. 2
  • The current regimen is clearly inadequate, with most postprandial and evening values exceeding 300 mg/dL consistently over weeks. 1

High-Risk Comorbidity Profile

  • Post-cerebellar stroke with gait instability increases fall risk, which is further amplified by potential hypoglycemia from aggressive insulin titration. 1
  • Paroxysmal atrial fibrillation on rivaroxaban creates bleeding risk if hypoglycemia occurs and the patient falls. 1
  • Carvedilol (non-selective beta-blocker) may mask hypoglycemic symptoms and enhance insulin's hypoglycemic effects, as noted in the drug interaction alert. 1

Discharge Insulin Regimen Based on Guidelines

If Discharge Must Proceed (Against Ideal Judgment)

The patient requires a basal-bolus insulin regimen, not continuation of the current inadequate therapy. 1

Basal Insulin Calculation

  • Calculate total daily insulin requirement: Current facility insulin use shows approximately 60 units total daily (30 units glargine BID + average 12-16 units aspart daily). 1
  • Discharge basal insulin should be 50-80% of hospital basal dose for elderly patients. 1
  • Recommended: Insulin glargine 20-25 units once daily at bedtime (approximately 70% of current 60-unit hospital basal dose). 1

Prandial Insulin

  • Add insulin aspart 4-6 units before each meal (approximately 10% of basal dose per meal). 1
  • This addresses the severe postprandial hyperglycemia (>300 mg/dL) that sliding scale alone cannot control. 1

Correction Insulin

  • Continue correction scale: 2 units for glucose 151-200,4 units for 201-250,6 units for 251-300,8 units for 301-350,10 units for 351-400, and 12 units for >400 mg/dL. 1

Oral Agent Considerations

Sitagliptin should be continued as it is safe in elderly patients with mild-moderate hyperglycemia and reduces hypoglycemia risk when combined with basal insulin. 1

  • The patient's eGFR of 87 mL/min allows full-dose sitagliptin (100 mg daily). 1
  • Evidence supports DPP-4 inhibitors plus basal insulin as an effective alternative to full basal-bolus regimens in elderly patients, though this patient's severity exceeds that evidence base. 1

Mandatory Discharge Requirements

Immediate Follow-Up Timing

Schedule endocrinology or primary care follow-up within 1 week, NOT 1 month, given the severe uncontrolled hyperglycemia and medication changes. 1

  • Patients with glycemic medication changes or suboptimal control require follow-up in 1-2 weeks. 1
  • Frequent telephone contact in the first week is essential to titrate insulin and prevent both hyperglycemia and hypoglycemia. 1

Home Health Nursing Orders

Home health nursing must include:

  • Fingerstick glucose monitoring before each meal and at bedtime (minimum 4 times daily). 1
  • Immediate provider notification for glucose <70 mg/dL or >400 mg/dL. 1
  • Insulin administration assistance and technique verification. 1
  • Assessment for hypoglycemia symptoms, especially given beta-blocker masking effect. 1

Medication Reconciliation and Supply

Provide at discharge:

  • Written prescriptions for insulin glargine, insulin aspart, and all syringes/pens with clear dosing instructions. 1
  • Blood glucose meter, test strips (minimum 120 strips for 4x daily testing for 1 month), and lancets. 1
  • Glucagon emergency kit (intranasal or subcutaneous) given high insulin doses and fall risk. 1
  • Complete medication list with clear documentation of which medications were changed versus continued. 1

Patient and Caregiver Education

Mandatory education topics:

  • Hypoglycemia recognition and treatment (15g fast-acting carbohydrate for glucose <70 mg/dL, recheck in 15 minutes). 1
  • Proper insulin injection technique, storage, and timing relative to meals. 1
  • Low-carbohydrate, low-sugar diet reinforcement with specific meal planning. 1
  • When to call provider or go to emergency department (glucose <60 or >400 mg/dL, confusion, inability to eat). 1

Critical Pitfalls to Avoid

Never Discharge on Sliding Scale Insulin Alone

Sliding scale insulin as sole therapy is strongly contraindicated and associated with poor outcomes and worse glycemic control. 1

  • This patient's current regimen includes basal insulin, but the inadequate dosing essentially functions as sliding scale-dominant therapy. 1

Do Not Continue Inadequate Therapy

Discharging on the current failing regimen (glargine 30 BID + sliding scale + sitagliptin) guarantees readmission for hyperglycemic complications. 1

  • The glucose log demonstrates clear treatment failure with this approach. 1

Beta-Blocker Interaction Awareness

Carvedilol will mask tachycardia and tremor symptoms of hypoglycemia; patient and caregivers must recognize confusion, sweating, and hunger as primary warning signs. 1

  • Consider whether carvedilol dose reduction is feasible given blood pressure control (recent BP 116-143 mmHg). 1

Avoid Metformin Initiation at Discharge

Do not add metformin at discharge despite its cardiovascular benefits, given the acute illness context, recent stroke, and need to focus on insulin titration first. 1

  • Metformin can be considered at 2-4 week follow-up once glycemic stability is achieved. 1

Alternative: Extended Facility Stay Recommendation

The medically appropriate recommendation is to extend the skilled nursing facility stay for 1-2 additional weeks to:

  • Aggressively titrate insulin to achieve pre-meal glucose 100-180 mg/dL and bedtime glucose <200 mg/dL. 1
  • Establish a stable, effective regimen before transitioning to less-supervised home environment. 1
  • Complete physical therapy goals for gait stability to reduce fall risk before managing complex insulin regimen at home. 1

This approach prioritizes mortality risk reduction (preventing hyperosmolar state, falls with intracranial hemorrhage on anticoagulation) and quality of life (avoiding readmission, achieving functional independence) over premature discharge. 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Management of Hyperglycemic Hyperosmolar State

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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