Preferred answer: Diet and exercise plus insulin
With a 10.2% A1c, his initial blood glucose control can be characterized as poor (see Table 1). He will need instruction on nutrition and exercise, and would benefit from insulin therapy to quickly establish good blood glucose control.
Table 1: Initial Control
It may be possible to stop the insulin later, but right now it is important to establish good control as rapidly as possible.
When initiating or changing therapy, a major factor in selecting a class of drugs, or a specific medication within a class, is the general level of glycemic control. The A1c level will determine in part which glycemic agent is selected, with consideration given to the more effective glycemia-lowering agent, insulin, for patients with A1c greater than 9.5% or with symptoms secondary to hyperglycemia.
In the setting of severely uncontrolled diabetes with catabolism, defined as fasting plasma glucose levels greater than 250 mg/dL (13.9 mmol/l), random glucose levels consistently greater than 300 mg/dL (16.7 mmol/l), A1c greater than 10%, or the presence of ketonuria, or as symptomatic diabetes with polyuria, polydipsia, and weight loss, insulin therapy in combination with lifestyle intervention is the treatment of choice.1
Although well-educated, the patient has been denying his condition. Significant diabetes education and perhaps psychological counseling may be necessary for him to accept his condition and treat it properly. Most patients, even those who are well-educated, are not knowledgeable enough to deal with their diabetes, so education is generally a cornerstone of diabetes therapy.
Titrating The Insulin Therapy
After a one hour meeting with a diabetes educator, the patient is judged to be capable of self-management. He will receive 10-15 more hours of education.
The A1c goal is set at <7% and/or mean plasma glucose >130 mg/dL, with a fasting blood glucose target <100 mg/dL within four months.
He is asked to write a contract which he then signs.
Patient is started on 10 U of glargine at bedtime using a SoloStar® pen with 8mm pen needles.
The patient will also follow a carbohydrate counting meal plan and self-monitor his blood glucose 4 times a day. He is taught to use the meter’s 3-day averaging function. The patient also decides to download his meter readings into the software that is available for his blood glucose meter.
The patient is taught to titrate his insulin doses based on his average fasting blood glucose in a 3-day period.
Patient is instructed in writing that every 3 days, if his average fasting blood glucose is >180 mg/dL, he should increase the glargine dose by 3-4 units.
If the average fasting blood glucose is between 130-180 mg/dL, he should increase the glargine dose by 1-2 units.
He will return in five weeks for evaluation. The patient is instructed to call the physician’s office if he experiences fasting blood glucose levels lower than 90 mg/dL, or any allergic reactions to the glargine, as described in the package insert.