A 55-year-old man comes to the emergency department due to progressive weakness and lethargy. The patient says that over the past 3 months he has been excessively thirsty and waking up several times at night to urinate. He has also lost 5 kg (11 lb) during this time despite no change in appetite. The patient has not seen a doctor in several years. Family history is significant for type 2 diabetes mellitus in his mother and father. Blood pressure is 108/60 mm Hg, and pulse is 98/min. BMI is 38 kg/m². Physical examination shows dry mucous membranes and poor skin turgor. Laboratory testing reveals a blood glucose concentration of 600 mg/dL. Serum beta-hydroxybutyrate is normal, and hemoglobin A1c is 14%. The patient is admitted, and intravenous fluids and insulin infusion are begun. The next day, his symptoms significantly improve, and the blood glucose levels normalize. In preparation for discharge, his insulin infusion is changed to a subcutaneous regimen that closely mimics the physiologic pattern of insulin release. This patient's insulin therapy was most likely transitioned to which of the following regimens?

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11ec160b_3bb3_4bee_9249_47e9cf91daf2_MD0001_00 This patient has polyuria, polydipsia, weight loss, and risk factors for type 2 diabetes mellitus that include obesity and a positive family history; the striking elevation in hemoglobin A1c confirms the diagnosis. He now has lethargy, dehydration (eg, dry mucous membranes), and severe hyperglycemia that is consistent with a hyperosmolar hyperglycemic state, a potential complication of untreated diabetes. He was appropriately managed with intravenous fluids and insulin and now needs to be transitioned to chronic insulin therapy. Insulin is normally secreted continuously by pancreatic beta cells 24 hours a day (basal insulin secretion). Then, following meals, insulin secretion increases transiently to control the postprandial surge in blood glucose as dietary sugar and digested carbohydrates are absorbed in the intestine. Physiologic insulin secretion can be approximated by a combination of long-acting and rapid-acting insulin analogs (ie, basal-bolus regimen). Long-acting preparations (eg, glargine) are released from the injection site continuously throughout the day and replicate basal insulin secretion. Concurrently, boluses of a rapid-acting insulin (eg, lispro) that is quickly absorbed are given with each meal to control postprandial glucose elevations. Alternately, an insulin pump can provide a steady supply of insulin throughout the day as well as mealtime dose increases. (Choice A) A regimen using NPH insulin and regular insulin twice daily does not closely replicate physiologic insulin secretion. NPH is an intermediate-acting insulin that has a significant (and delayed) peak effect, increasing the risk of hypoglycemia between doses. In addition, regular insulin can polymerize at the injection site, causing a short delay in absorption leading to higher postprandial glucose levels. (Choice B) Insulin aspart alone can replicate postprandial insulin secretion but does not provide basal insulin effect. (Choices C and D) Insulin glargine alone provides a basal insulin effect, while insulin detemir, given once or twice daily, has a shorter duration of effect than glargine but can be used as basal insulin in some patients; however, neither provides appropriate mealtime coverage to control postprandial glucose. Educational objective: Physiologic insulin secretion can be approximated by a combination of long-acting and rapid-acting insulin analogs. Long-acting preparations (eg, glargine) are released from the injection site slowly throughout the day and replicate basal insulin secretion. Boluses of a rapid-acting insulin (eg, lispro) with quick absorption are given with meals to control postprandial glucose elevations. __________ References: A review of basal-bolus therapy using insulin glargine and insulin lispro in the management of diabetes mellitus. (http://www.ncbi.nlm.nih.gov/pubmed/29654514)

A 55-Year-Old Man Comes to the Emergency Department Due to Progressive