What discharge plan, including insulin regimen, diet, exercise, and adjunct therapies, should be recommended for a 53‑year‑old male with type 2 diabetes, hemoglobin A1c 12 %, BMI 40 (≈140 kg), currently on basal insulin glargine (Lantus) 50 U daily with a carbohydrate‑to‑insulin ratio of 1 U per 8 g carbohydrate and an insulin‑sensitivity factor of 25 mg/dL per unit, and bedside glucose readings of 200–300 mg/dL?

Discharge Recommendations for Severe Uncontrolled Type 2 Diabetes

Immediate Insulin Regimen Restructuring

This patient requires aggressive basal-bolus insulin therapy immediately, not sliding-scale monotherapy. With an HbA1c of 12% and glucose readings of 200–300 mg/dL, the current regimen of Lantus 50 U is grossly inadequate and must be intensified 1, 2.

Basal Insulin Adjustment

• Increase Lantus to 70 U once daily (0.5 U/kg for 140 kg) administered at bedtime 1, 2
• Titrate by 4 U every 3 days until fasting glucose consistently reaches 80–130 mg/dL 1, 2
• Critical threshold: Do not escalate basal insulin beyond 0.5–1.0 U/kg/day (70–140 U) without adding prandial coverage, as this leads to "overbasalization" with increased hypoglycemia risk without improved control 1, 2

Prandial Insulin Initiation

• Start rapid-acting insulin (lispro, aspart, or glulisine) at 10–12 U before each of the three main meals 1, 2
• Administer 0–15 minutes before meals for optimal postprandial control 1, 3
• Titrate each meal dose by 2 U every 3 days based on 2-hour postprandial glucose, targeting <180 mg/dL 1, 2

Correction Insulin Protocol

• Add 2 U rapid-acting insulin for pre-meal glucose >250 mg/dL 1
• Add 4 U rapid-acting insulin for pre-meal glucose >350 mg/dL 1
• These correction doses are in addition to scheduled prandial insulin, never as a replacement 1

Metformin Optimization – Critical Foundation Therapy

Metformin must be continued and optimized to 2000 mg daily (1000 mg twice daily with meals) unless contraindicated. 1, 2 The combination of metformin with insulin reduces total insulin requirements by 20–30%, provides superior glycemic control, and limits weight gain compared to insulin alone 1, 2. This is non-negotiable for optimal outcomes.

Weight Management and Lifestyle Intervention

Nutrition Therapy

• Refer to a registered dietitian for individualized medical nutrition therapy emphasizing nutrient-dense foods with appropriate portions 3
• Implement carbohydrate counting to determine mealtime insulin dosing using the 1:8 carb ratio already established 3
• Avoid sugar-sweetened beverages and minimize foods with added sugars 3
• Target ≥5% weight loss through calorie reduction, which will significantly improve insulin sensitivity and reduce insulin requirements 3

Exercise Prescription

• 150 minutes weekly of moderate-intensity aerobic exercise (e.g., brisk walking), spread over at least 3 days with no more than 2 consecutive days without activity 3
• Regular physical activity decreases insulin resistance and may reduce insulin requirements by 20–30% 1
• Resistance training 2–3 times weekly on non-consecutive days 3

Glucose Monitoring Protocol

• Check fasting glucose every morning to guide basal insulin titration 1, 2
• Check pre-meal glucose before each meal to calculate correction doses 1
• Check 2-hour postprandial glucose after each meal to assess prandial insulin adequacy 1, 2
• Check bedtime glucose to ensure overnight safety 1
• Minimum 4 checks daily during intensive titration phase 1

Hypoglycemia Management Education

• Treat any glucose <70 mg/dL immediately with 15 g fast-acting carbohydrate (4 glucose tablets, 4 oz juice, or 3–4 hard candies) 1, 2
• Recheck glucose in 15 minutes and repeat treatment if still <70 mg/dL 1
• If hypoglycemia occurs without obvious cause, reduce the implicated insulin dose by 10–20% before the next administration 1, 2
• Provide glucagon emergency kit and train family member on administration 1

Expected Clinical Outcomes

• With properly implemented basal-bolus therapy, 68% of patients achieve mean glucose <140 mg/dL versus only 38% with inadequate sliding-scale approaches 1
• Expect HbA1c reduction of 3–4% (from 12% to approximately 8–9%) over 3–6 months with aggressive insulin titration 1
• Properly dosed basal-bolus regimens do not increase hypoglycemia risk compared with inadequate monotherapy when correctly implemented 1

Follow-Up Schedule

• 1–2 weeks post-discharge: Primary care or endocrinology visit to assess glucose control, review downloaded meter data, and adjust insulin doses 1, 3
• Monthly visits until HbA1c falls below 9% 4, 1
• Check HbA1c every 3 months during intensive management 2, 3
• Urgent endocrinology referral required for HbA1c >9% with unstable glucose patterns 4, 1

Discharge Medication Reconciliation

Medication	Dose/Instruction
Lantus (insulin glargine)	70 U subcutaneously once daily at bedtime
Rapid-acting insulin	10–12 U before breakfast, lunch, and dinner
Metformin	1000 mg twice daily with meals
Glucose meter & test strips	Minimum 4 checks daily
Ketone testing strips	Check when glucose >300 mg/dL with nausea/vomiting
Glucagon emergency kit	For severe hypoglycemia

Critical Pitfalls to Avoid

• Never use sliding-scale insulin as monotherapy – this approach is condemned by all major diabetes guidelines and achieves adequate control in only 38% of patients 1
• Never delay prandial insulin addition when pre-meal glucose consistently exceeds 250 mg/dL and HbA1c >10% 1
• Never discontinue metformin when starting or intensifying insulin unless medically contraindicated 1, 2
• Never give rapid-acting insulin solely at bedtime as a correction dose, as this markedly increases nocturnal hypoglycemia risk 1
• Never continue escalating basal insulin beyond 0.5–1.0 U/kg/day without concurrent prandial coverage 1, 2

Patient Education Essentials

• Insulin injection technique and site rotation to prevent lipohypertrophy 1
• Sick-day management: Continue insulin even if not eating, check glucose every 4 hours, maintain hydration, check ketones if glucose >300 mg/dL 1
• Ketone testing when glucose >300 mg/dL with nausea, vomiting, or abdominal pain 1
• Insulin storage: Keep unopened vials refrigerated; in-use vials can remain at room temperature for up to 28 days 1

Adjunct Therapy Consideration

• Consider adding a GLP-1 receptor agonist (e.g., semaglutide, dulaglutide) once basal insulin is optimized if HbA1c remains >8% after 3–6 months 1, 2, 5. GLP-1 agonists provide comparable or superior HbA1c reduction to prandial insulin intensification with the added benefits of weight loss (critical for BMI 40) and lower hypoglycemia risk 5.