What is the best course of action for a 53-year-old female patient with a history of diabetes mellitus (DM), hypertension, hyperlipidemia, vision impairment, and myocardial infarction, currently being treated for pneumonia (PNA) with Levofloxacin (Levaquin), and requiring tighter control of her uncontrolled diabetes, with a recent hemoglobin A1c (HbA1c) level indicating poor glycemic control?

From the Guidelines

The patient requires immediate intervention for her uncontrolled diabetes management, particularly given her visual impairment and dangerous practice of injecting random amounts of insulin. To address her diabetes control, I recommend implementing a multi-faceted approach.

• First, arrange for a diabetes educator to visit her home to establish a simplified insulin administration system using pre-filled pens with tactile or audible dose indicators designed for visually impaired patients, as her current practice puts her at high risk for both hypoglycemic events and continued poor glycemic control 1.
• Second, increase her home health aide visits to include supervision of insulin administration until she demonstrates consistent proper technique, ensuring that she is taking the correct dose of insulin, which can be initiated at 10 units per day or 0.1-0.2 units/kg per day, with titration based on an evidence-based algorithm to reach her FPG goal without hypoglycemia 1.
• Third, schedule an urgent follow-up with her primary care physician within one week of hospital discharge to reassess her diabetes medication regimen, with consideration of switching to a simplified insulin regimen with fewer daily injections or exploring continuous glucose monitoring with voice feedback features, and consider adding a GLP-1 RA or dual GIP and GLP-1 RA if her A1C remains above goal 1.
• Fourth, ensure proper medication adherence by having the home health aide verify that she's using the pill box correctly and refill it weekly, as her last HbA1c was 9.0, indicating poor glycemic control, and her hospitalization for pneumonia highlights the need for improved overall health management. Her recent pneumonia hospitalization and HbA1c of 9.0 indicate that her overall health management requires immediate attention, with diabetes control being a priority to prevent further complications, particularly given her history of cardiovascular disease and other comorbidities.

From the FDA Drug Label

5.3 Hypoglycemia Hypoglycemia is the most common adverse reaction associated with insulins, including Insulin Glargine. Severe hypoglycemia can cause seizures, may be life-threatening or cause death. Hypoglycemia can impair concentration ability and reaction time; this may place the patient and others at risk in situations where these abilities are important (e.g., driving or operating other machinery). The long-acting effect of Insulin Glargine may delay recovery from hypoglycemia. Risk Factors for Hypoglycemia The risk of hypoglycemia after an injection is related to the duration of action of the insulin and, in general, is highest when the glucose lowering effect of the insulin is maximal As with all insulins, the glucose lowering effect time course of Insulin Glargine may vary in different patients or at different times in the same patient and depends on many conditions, including the area of injection as well as the injection site blood supply and temperature Other factors which may increase the risk of hypoglycemia include changes in meal pattern (e.g., macronutrient content or timing of meals), changes in level of physical activity, or changes to concomitant drugs Patients with renal or hepatic impairment may be at higher risk of hypoglycemia

The patient has a history of uncontrolled diabetes with a last HbA1c of 9.0 and reports injecting a random number of insulin units due to visual impairment. Close monitoring of blood glucose levels is essential to prevent and manage hypoglycemia, especially in patients with reduced symptomatic awareness of hypoglycemia, such as those with longstanding diabetes or diabetic neuropathy 2.

• Risk factors for hypoglycemia include changes in meal pattern, physical activity, or concomitant drugs, as well as renal or hepatic impairment.
• Education on recognizing and managing hypoglycemia is crucial for the patient and caregivers. Given the patient's history of uncontrolled diabetes and visual impairment, increased frequency of blood glucose monitoring is recommended to mitigate the risk of hypoglycemia 3.

From the Research

Patient's Current Condition

The patient is a 53-year-old female with a complex medical history, including diabetes mellitus, hypertension, hyperlipidemia, vision impairment, and a history of myocardial infarction. Her current concern is the management of her diabetes, with a recent HbA1c level of 9.0, indicating poorly controlled diabetes.

Management of Diabetes

• The patient's visual impairment affects her ability to manage her insulin doses, leading to random insulin injections.
• Studies suggest that insulin therapy should be considered for patients with type 2 diabetes and HbA1c levels exceeding 9.0% 4.
• However, other studies indicate that oral agents, such as metformin, and incretin-based treatments may be effective alternatives to insulin therapy for patients with HbA1c levels above 9.0% 4.
• The use of GLP-1 receptor agonists, such as exenatide, has been shown to be effective in reducing HbA1c levels and may be a suitable alternative to insulin therapy 4, 5.

Insulin Therapy

• Safe adjustment of insulin therapy requires review of both long-term and short-term glycaemic control, HbA1c and blood glucose monitoring (BGM), respectively 6.
• Studies have compared the efficacy and safety of different insulin regimens, including biphasic insulin aspart 70/30 and once-daily insulin glargine, in patients with type 2 diabetes mellitus inadequately controlled on basal insulin and oral therapy 7.
• The combination of insulin glargine and lixisenatide has been shown to be more effective than insulin degludec and insulin aspart in reducing HbA1c levels and body weight, with a lower incidence of hypoglycaemia 5.

Alternative Treatment Approaches

• Switching from a glargine+insulin aspart regimen to a glargine+insulin aspart 30 regimen before breakfast, combined with exercise after dinner and dividing meals, has been shown to improve glucose control in patients with poorly controlled type 2 diabetes 8.
• This approach may be a suitable alternative to traditional insulin therapy, especially for patients with visual impairment or other challenges in managing their insulin doses.