Prescription Sheet for Adult Patient with Type 2 Diabetes Mellitus
Patient Name: ___________________________
Date: ___________________________
Medical Record Number: ___________________________
Date of Birth: ___________________________
Weight: ___________ kg
Current Medications
- Metformin 500 mg – Take 1 tablet by mouth twice daily with meals
- Sitagliptin 50 mg – Take 1 tablet by mouth once daily
New Prescriptions
1. Insulin Glargine (Lantus) 100 units/mL
- Dose: Start with 10 units subcutaneously once daily at bedtime (or 0.1–0.2 units/kg if weight-based dosing preferred) 1
- Administration: Inject subcutaneously in the abdomen, thigh, or upper arm at the same time each evening 1
- Titration Schedule:
- Increase dose by 2 units every 3 days if fasting glucose is 140–179 mg/dL 1
- Increase dose by 4 units every 3 days if fasting glucose is ≥180 mg/dL 1
- Target fasting glucose: 80–130 mg/dL 1
- If any glucose reading falls <70 mg/dL, reduce the current dose by 10–20% immediately and treat with 15 g fast-acting carbohydrate 1
- Critical threshold: When basal insulin approaches 0.5 units/kg/day without achieving glycemic targets, consider adding prandial insulin rather than continuing to escalate basal insulin alone to avoid "over-basalization" 1
- Dispense: 1 vial (10 mL) or 5 FlexTouch pens (3 mL each)
- Refills: 3
2. Metformin Extended-Release (ER) 1000 mg
- Dose: Take 1 tablet by mouth once daily with the evening meal 2
- Rationale: Continue metformin at maximum tolerated dose (up to 2000–2550 mg daily) when adding insulin; metformin reduces total insulin requirements by 20–30% and provides superior glycemic control compared to insulin alone 1
- Monitoring: Check eGFR at least annually if ≥60 mL/min/1.73 m²; increase to every 3–6 months if eGFR <60 mL/min/1.73 m² 2, 3
- Dose adjustment for renal function:
- Dispense: 90 tablets
- Refills: 3
3. Sitagliptin 100 mg
- Dose: Take 1 tablet by mouth once daily 4, 5
- Rationale: Adding sitagliptin to metformin provides an additional 0.5–0.8% HbA1c reduction, improves beta-cell function, and is generally well-tolerated with minimal hypoglycemia risk 4, 5, 6
- Renal adjustment: If eGFR falls to 30–44 mL/min/1.73 m², reduce to 50 mg daily; if eGFR <30 mL/min/1.73 m², reduce to 25 mg daily 3
- Dispense: 90 tablets
- Refills: 3
4. Blood Glucose Test Strips and Lancets
- Frequency: Check fasting glucose daily during insulin titration 1
- Additional monitoring: Check pre-meal glucose if prandial insulin is added later 1
- Dispense: 100 test strips and 100 lancets per month
- Refills: 3
5. Glucose Meter (if not already provided)
- Dispense: 1 glucose meter with instruction manual
- Refills: 0
Patient Education and Safety Instructions
Insulin Administration
- Inject insulin glargine at the same time each evening (preferably at bedtime) 1
- Rotate injection sites within the same anatomical region to prevent lipohypertrophy 1
- Never share insulin pens, needles, or syringes between patients 7
Hypoglycemia Management
- Treat any glucose <70 mg/dL immediately with 15 g of fast-acting carbohydrate (4 glucose tablets or 4 oz juice), recheck in 15 minutes, and repeat if needed 1
- Symptoms include shakiness, sweating, confusion, rapid heartbeat 1
- Always carry a source of fast-acting carbohydrate 1
Monitoring Requirements
- Check fasting glucose every morning during titration 1
- Record all glucose values to guide dose adjustments every 3 days 1
- Contact provider if fasting glucose remains >180 mg/dL after 2–3 weeks of titration 1
- Contact provider immediately if glucose falls <70 mg/dL 1
Sick Day Management
- Continue insulin even if not eating to prevent ketoacidosis 1
- Check glucose every 4 hours during illness 1
- Maintain adequate hydration 1
- Temporarily discontinue metformin during acute illness causing volume depletion (severe infection, diarrhea, vomiting, dehydration) 3
Metformin Safety
- Take metformin with meals to minimize gastrointestinal side effects 2
- Hold metformin before iodinated contrast procedures if you have liver disease, alcoholism, or heart failure; re-check eGFR 48 hours after procedure before restarting 3
- Monitor for vitamin B12 deficiency if on metformin for >4 years 2, 3
Follow-Up Plan
Week 1–3 (Titration Phase)
- Patient self-adjusts insulin dose every 3 days based on fasting glucose readings using the titration schedule above 1
- Daily fasting glucose monitoring 1
Week 4
- Office visit to review glucose log, assess for hypoglycemia, and evaluate overall glycemic control 1
- Check HbA1c if not done in past 3 months 8
Month 3
- Office visit to reassess HbA1c and determine if further intensification is needed 1
- If HbA1c remains >7% despite achieving fasting glucose 80–130 mg/dL, consider adding prandial insulin 1
- If basal insulin dose approaches 0.5 units/kg/day without achieving targets, add prandial insulin (start with 4 units before the largest meal) 1
Ongoing
- Monitor eGFR at least annually if ≥60 mL/min/1.73 m²; every 3–6 months if <60 mL/min/1.73 m² 2, 3
- Check HbA1c every 3 months during intensive titration 1
- Assess for cardiovascular disease, heart failure, or chronic kidney disease; if present, consider adding SGLT2 inhibitor or GLP-1 receptor agonist with proven cardiovascular benefit 8
Common Pitfalls to Avoid
- Do not delay insulin initiation in patients not achieving glycemic goals with oral medications; prolonged hyperglycemia increases complication risk 1
- Do not discontinue metformin when starting insulin unless contraindicated; this leads to higher insulin requirements and more weight gain 1
- Do not continue escalating basal insulin beyond 0.5–1.0 units/kg/day without addressing postprandial hyperglycemia; this causes over-basalization with increased hypoglycemia risk 1
- Do not use sliding-scale insulin as monotherapy; it is condemned by major diabetes guidelines and causes dangerous glucose fluctuations 1
Prescriber Signature: ___________________________
Prescriber Name (Print): ___________________________
License Number: ___________________________
DEA Number (if applicable): ___________________________
Date: ___________________________
Contact Information for Questions:
Phone: ___________________________
After-Hours Emergency: ___________________________