Discharge Recommendations for Type 2 Diabetes with Inadequate Glycemic Control

Immediate Insulin Regimen Adjustment

• The American Diabetes Association recommends aggressive insulin intensification with a basal-bolus regimen at discharge for patients with blood glucose levels consistently in the 200-250 mg/dL range and an A1C of 10.4%, indicating both inadequate basal coverage and significant postprandial hyperglycemia requiring mealtime insulin 1

Recommended Discharge Insulin Regimen

• The American Association of Clinical Endocrinologists recommends increasing Lantus to 20 units once daily at bedtime and adding rapid-acting insulin 4-6 units before each of the three largest meals for a patient with inadequate glycemic control 1
• The Endocrine Society recommends a total daily dose of approximately 0.44-0.55 units/kg/day, which is appropriate for an A1C >10% 1

Titration Instructions for Patient

• The American Diabetes Association recommends increasing Lantus by 4 units every 3 days if fasting glucose remains ≥180 mg/dL, and by 2 units every 3 days if fasting glucose is 140-179 mg/dL 1
• The American Association of Clinical Endocrinologists recommends a target fasting glucose of 80-130 mg/dL 2, 1
• The Endocrine Society recommends reducing Lantus dose by 10-20% immediately if hypoglycemia occurs (glucose <70 mg/dL) 1

Prandial Insulin Titration

• The American Diabetes Association recommends increasing prandial insulin by 1-2 units every 3 days if 2-hour postprandial glucose consistently exceeds 180 mg/dL 1
• The American Association of Clinical Endocrinologists recommends a target postprandial glucose of <180 mg/dL 2

Foundation Oral Therapy

• The American Diabetes Association recommends continuing metformin at maximum tolerated dose (up to 2000-2550 mg daily) unless contraindicated, as it provides superior glycemic control with reduced insulin requirements and less weight gain compared to insulin alone 1

Patient Education Requirements

• The American Association of Clinical Endocrinologists recommends providing comprehensive education on insulin injection technique and site rotation, self-monitoring of blood glucose, hypoglycemia recognition and treatment, sick day management, and insulin storage and handling 3, 2, 1

Monitoring and Follow-Up

• The American Diabetes Association recommends scheduling a follow-up appointment within 1-2 weeks given significant medication changes and suboptimal glucose control, and checking A1C in 3 months to assess overall glycemic control 3, 2, 1
• The Endocrine Society recommends daily fasting blood glucose monitoring during titration, and expects an A1C reduction of 2-3% from baseline with appropriate basal-bolus therapy 1

Medication Reconciliation

• The American Association of Clinical Endocrinologists recommends ensuring patient has adequate supply of insulin syringes or pen needles, blood glucose meter, and test strips, and verifying insurance coverage for prescribed insulins 3

Critical Pitfalls to Avoid

• The American Diabetes Association recommends never discharging a patient on basal insulin alone with blood glucose consistently 200-250 mg/dL, and never using sliding scale insulin as monotherapy, as it results in dangerous glucose fluctuations 1
• The Endocrine Society recommends never discontinuing metformin when intensifying insulin unless contraindicated, as it leads to higher insulin requirements and more weight gain 1

Expected Outcomes

• The American Association of Clinical Endocrinologists expects mean blood glucose <140 mg/dL and A1C reduction to approximately 7-8% over 3-6 months with appropriate basal-bolus therapy at weight-based dosing 1