What discharge insulin regimen and titration plan should be prescribed for a 53‑year‑old man with severe obesity (BMI 40, weight ≈ 140 kg) and markedly uncontrolled type 2 diabetes (HbA1c 12 %) who is currently on insulin glargine (Lantus) 50 U daily with a carbohydrate‑to‑insulin ratio of 1 U per 8 g carbohydrate?

Discharge Insulin Regimen for Severe Uncontrolled Type 2 Diabetes

This patient requires immediate aggressive basal‑bolus insulin therapy with a starting total daily dose of 42–70 units (0.3–0.5 U/kg/day), split 50% basal and 50% prandial, combined with optimized metformin 2000 mg daily.

Immediate Discharge Insulin Regimen

Basal Insulin (Lantus)

• Start with 56 units once daily at bedtime (0.4 U/kg/day for 140 kg) 1
• Titrate by 4 units every 3 days until fasting glucose reaches 80–130 mg/dL 1, 2
• Critical threshold: Stop escalating basal insulin when dose approaches 70 units (0.5 U/kg/day); at that point, intensify prandial insulin instead to avoid over‑basalization 1, 2

Prandial Insulin (Rapid‑Acting)

• Start with 10 units before each of the three largest meals (breakfast, lunch, dinner) 1, 2
• Administer 0–15 minutes before eating 1
• Titrate each meal dose by 2 units every 3 days based on 2‑hour post‑meal glucose, targeting <180 mg/dL 1, 2

Correction Insulin Protocol

• Add 2 units rapid‑acting insulin for pre‑meal glucose >250 mg/dL 1
• Add 4 units rapid‑acting insulin for pre‑meal glucose >350 mg/dL 1
• These correction doses are in addition to scheduled prandial insulin 1

Foundation Oral Therapy

Metformin Optimization

• Increase metformin to 1000 mg twice daily (2000 mg total) unless contraindicated 1, 2
• Metformin reduces total insulin requirements by 20–30% and provides superior glycemic control when combined with insulin 1
• Never discontinue metformin when starting or intensifying insulin unless medically contraindicated 1

Glucose Monitoring Requirements

• Fasting glucose daily to guide basal insulin titration 1, 2
• Pre‑meal glucose before each meal to calculate correction doses 1
• 2‑hour post‑meal glucose to guide prandial insulin adjustments 1, 2
• Bedtime glucose for safety monitoring 1
• Minimum 4 checks daily during active titration 1

Expected Clinical Outcomes

• With properly implemented basal‑bolus therapy, 68% of patients achieve mean glucose <140 mg/dL versus only 38% with sliding‑scale insulin alone 1
• Anticipated HbA1c reduction of 3–4% (from 12% to 8–9%) over 3–6 months with intensive titration 1, 2
• No increased hypoglycemia risk when basal‑bolus regimens are correctly implemented versus inadequate sliding‑scale approaches 1

Hypoglycemia Management Protocol

• Treat any glucose <70 mg/dL immediately with 15 grams of fast‑acting carbohydrate 1
• Re‑check in 15 minutes and repeat if needed 1
• If hypoglycemia occurs without obvious cause, reduce the implicated insulin dose by 10–20% immediately 1, 2
• Patient must carry fast‑acting carbohydrate source at all times 1

Critical Pitfalls to Avoid

• Never use sliding‑scale insulin as monotherapy—major diabetes guidelines condemn this approach as ineffective and dangerous 1
• Do not continue escalating basal insulin beyond 0.5–1.0 U/kg/day (70–140 units) without addressing postprandial hyperglycemia; this leads to over‑basalization with increased hypoglycemia risk 1, 2
• Do not delay prandial insulin addition when HbA1c is 12% and pre‑meal glucose consistently exceeds 250 mg/dL 1
• Never give rapid‑acting insulin solely at bedtime as a correction dose—this markedly increases nocturnal hypoglycemia risk 1

Patient Education Essentials

• Insulin injection technique and site rotation to prevent lipohypertrophy 1
• Hypoglycemia recognition and treatment: symptoms, <70 mg/dL threshold, 15‑gram carbohydrate rule 1
• Sick‑day management: continue insulin even if not eating, check glucose every 4 hours, maintain hydration 1
• Ketone testing when glucose >300 mg/dL with nausea or vomiting 1

Follow‑Up Schedule

• 1–2 weeks post‑discharge: primary care or endocrinology visit to assess glucose control 1
• Monthly visits until HbA1c falls below 9%; thereafter every 3 months 1
• HbA1c reassessment every 3 months during intensive titration 2
• Urgent endocrinology referral required for HbA1c >9% with unstable glucose 1

Rationale for Aggressive Approach

• This patient's HbA1c of 12% with BMI 40 represents severe uncontrolled diabetes requiring immediate basal‑bolus therapy, not gradual titration 1, 2
• The current regimen of Lantus 50 units alone is grossly inadequate—basal insulin addresses only fasting glucose, not the postprandial hyperglycemia driving this HbA1c 1
• Insulin is the most effective agent when HbA1c is ≥9%, and this patient's level of 12% warrants immediate intensive therapy 3
• For severe hyperglycemia (HbA1c >10%), guidelines recommend starting doses of 0.3–0.5 U/kg/day as total daily insulin 1, 2

Alternative Consideration

• If the patient continues to struggle with glycemic control despite optimized basal‑bolus insulin after 3–6 months, consider adding a GLP‑1 receptor agonist to improve control while minimizing weight gain and hypoglycemia risk 2