What discharge recommendations are appropriate for a 53‑year‑old man with type 2 diabetes mellitus (hemoglobin A1c 12 %), body mass index 40 kg/m², weight 140 kg, normal renal function, admitted for a scrotal abscess, currently on basal insulin glargine (Lantus) 50 U daily with a 1 U per 8 g carbohydrate ratio and an insulin‑sensitivity factor of 25 mg/dL, and capillary glucose 200‑300 mg/dL?

Discharge Recommendations for Severe Uncontrolled Type 2 Diabetes with Acute Infection

This patient requires immediate aggressive insulin intensification with a basal-bolus regimen at discharge, not continuation of the current inadequate insulin doses. With an HbA1c of 12%, BMI 40, and persistent blood glucose 200-300 mg/dL despite hospitalization, the current regimen of Lantus 50 units with 1:8 carb ratio is grossly insufficient and must be restructured before discharge 1.

Immediate Insulin Regimen Restructuring

Increase basal insulin aggressively and add structured prandial coverage:

• Basal insulin (Lantus): Increase from 50 units to 70-80 units once daily (approximately 0.5 units/kg/day for 140 kg), administered at bedtime 1, 2
• Prandial insulin: Initiate 10-12 units of rapid-acting insulin (lispro, aspart, or glulisine) before each of the three largest meals 1, 2
• Correction insulin: Add 2 units for pre-meal glucose >250 mg/dL and 4 units for glucose >350 mg/dL, in addition to scheduled prandial doses 1, 2

The current 1:8 carb ratio is inadequate for this degree of hyperglycemia and should be replaced with fixed prandial dosing initially, then transitioned to carb counting once glucose stabilizes 1, 2.

Critical Threshold Recognition

Stop escalating basal insulin when it approaches 0.5-1.0 units/kg/day (70-140 units) without achieving targets. At that point, further increases in basal insulin cause "overbasalization" with increased hypoglycemia risk rather than improved control 1, 2. This patient is already at the threshold where prandial insulin is mandatory, not optional 1, 2.

Foundation Oral Therapy

Metformin must be optimized or initiated:

• Start or increase metformin to 2000 mg daily (1000 mg twice daily) unless contraindicated by the scrotal abscess infection or renal function 1, 2
• Metformin reduces total insulin requirements by 20-30% and provides superior glycemic control when combined with insulin 1, 2
• With normal creatinine, metformin is safe and should be continued even with intensive insulin therapy 1, 2

Infection-Related Insulin Resistance

The scrotal abscess significantly increases insulin requirements through inflammatory cytokines and counter-regulatory hormones:

• Acute infections typically increase insulin needs by 40-60% above baseline 3, 4
• Insulin resistance will persist until the infection fully resolves, requiring continued aggressive dosing 3, 4
• Do not reduce insulin doses prematurely as the infection clears; wait for documented glucose stability below 180 mg/dL 3

Diabetes is a major risk factor for severe genitourinary infections including progression to Fournier's gangrene, making aggressive glucose control during and after infection treatment critical 5, 4.

Structured Discharge Titration Protocol

Provide explicit self-titration instructions:

Basal Insulin Titration

• Check fasting glucose daily before breakfast 1, 2
• If fasting glucose 140-179 mg/dL: increase Lantus by 2 units every 3 days 1, 2
• If fasting glucose ≥180 mg/dL: increase Lantus by 4 units every 3 days 1, 2
• Target fasting glucose 80-130 mg/dL 1, 2

Prandial Insulin Titration

• Check glucose 2 hours after each meal 1, 2
• If postprandial glucose consistently >180 mg/dL: increase that meal's insulin by 2 units every 3 days 1, 2
• Target postprandial glucose <180 mg/dL 1, 2

Hypoglycemia Protocol

• Treat any glucose <70 mg/dL immediately with 15 grams fast-acting carbohydrate 1, 2
• If hypoglycemia occurs without clear cause, reduce the implicated insulin dose by 10-20% immediately 1, 2

Mandatory Follow-Up Schedule

Early and frequent follow-up is non-negotiable with HbA1c 12%:

• 1-2 weeks post-discharge: Primary care or endocrinology visit to assess glucose control and infection resolution 1
• Monthly visits until HbA1c <9%, then every 3 months 1
• Urgent endocrinology referral is required for HbA1c >9% with unstable glucose control 1

With HbA1c 12%, this patient requires specialist diabetes management, not primary care alone 1.

Patient Education Essentials

Survival-skill diabetes education must include:

• Insulin injection technique and site rotation to prevent lipohypertrophy 1
• Hypoglycemia recognition and treatment: symptoms, glucose <70 mg/dL threshold, 15-gram carbohydrate rule 1, 2
• Sick day management: continue insulin even when not eating, check glucose every 4 hours, maintain hydration 1
• Glucose monitoring: minimum 4 times daily (fasting, before meals, bedtime) during titration 1, 2
• Ketone testing: check urine or blood ketones if glucose >300 mg/dL with nausea/vomiting 1, 2

Common Pitfalls to Avoid

Never continue the current inadequate regimen:

• Do not discharge on sliding-scale insulin alone—this approach is condemned by all major diabetes guidelines and achieves target glucose in only 38% of patients versus 68% with basal-bolus therapy 1, 2
• Do not delay prandial insulin addition when glucose is consistently 200-300 mg/dL with HbA1c 12%—this clearly indicates need for both basal and meal coverage 1, 2
• Do not continue escalating basal insulin beyond 0.5 units/kg/day without addressing postprandial hyperglycemia—this causes overbasalization with increased hypoglycemia and suboptimal control 1, 2
• Do not stop metformin when intensifying insulin unless contraindicated—this leads to 20-30% higher insulin requirements and more weight gain 1, 2

Expected Outcomes

With appropriate basal-bolus therapy at weight-based dosing:

• 68% of patients achieve mean glucose <140 mg/dL versus 38% with inadequate regimens 1, 2
• HbA1c reduction of 3-4% is achievable over 3-6 months (from 12% to 8-9%) 1, 2
• No increased hypoglycemia risk when properly implemented compared to inadequate sliding-scale approaches 1, 2

Medication Reconciliation at Discharge

Discharge prescriptions must include:

• Lantus 70-80 units subcutaneously once daily at bedtime 1, 2
• Rapid-acting insulin (lispro, aspart, or glulisine) 10-12 units before breakfast, lunch, and dinner 1, 2
• Metformin 1000 mg twice daily with meals (if not contraindicated) 1, 2
• Glucose meter and test strips: minimum 4 tests daily 1, 2
• Ketone testing strips (urine or blood) 1, 2
• Glucagon emergency kit for severe hypoglycemia 1, 2