A 26-year-old man comes to the office for a new patient visit. Three months ago, he was seen at an urgent care clinic for excessive thirst and frequent urination. Laboratory evaluation at that time revealed blood glucose of 384 mg/dL, normal anion gap, and hemoglobin A1c of 11.4%. Several medications were prescribed, but the patient was able to afford only regular insulin. He has been taking the insulin before meals, which has improved symptoms. Home fingerstick glucose readings have usually been at 100-300 mg/dL but have dropped as low as 65 mg/dL after he skipped a meal. The patient has complied with a diabetic dietary regimen but sometimes eats "junk food" when busy at work. Medical history is otherwise unremarkable. The patient's mother and sister have hypothyroidism, and his father died at a young age from a motor vehicle collision. There is no family history of diabetes mellitus. The patient is employed as a construction worker and does not use alcohol, tobacco, or illicit drugs. Blood pressure is 127/78 mm Hg and pulse is 76/min. BMI is 24 kg/m² and waist circumference is 83.8 cm (33 in). Physical examination, including monofilament testing of the feet, is normal. Laboratory results are as follows: The patient is referred for financial assistance and is now able to afford diabetes-related care. Which of the following is the most appropriate next step in management of this patient?

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Explanation: 11ec2b69_beb5_5d54_8f63_f1496d230c27_MD0005_00 This young patient with a normal BMI developed significant hyperglycemia with osmotic symptoms (polyuria, polydipsia) suggesting type 1 diabetes mellitus (T1DM). Patients with T1DM have severe insulin deficiency secondary to autoimmune destruction of pancreatic beta cells. Treatment focuses on replacing insulin in a pattern that mimics normal physiologic insulin secretion. This is typically achieved with: Basal-bolus insulin: Long-acting (eg, glargine) or intermediate-acting (eg, NPH) insulin once or twice daily to provide baseline coverage Premeal bolus insulin: Short-acting (eg, regular) or rapid-acting insulin prior to meals Both basal and premeal insulin are required to achieve adequate glucose control. This patient has been taking premeal insulin only; he requires the addition of basal-bolus insulin. (Choice A) Metformin directly improves the action of insulin and is often used as part of initial medication management of type 2 diabetes mellitus. Compared with patients with T1DM, patients with type 2 diabetes are often obese, age >45, and asymptomatic at diagnosis. This young patient with a normal BMI and osmotic symptoms is more likely to have T1DM; metformin would be ineffective. (Choice B) Dietary modifications and exercise are key components of T1DM management but are unlikely to generate effective glycemic control without appropriate insulin therapy. (Choice D) Once patients achieve well-established glycemic control, they can remain on multiple daily injection therapy or be converted to a continuous insulin infusion pump. Although pumps allow for more flexibility in meal times and may provide slightly better glucose control, they are expensive and require wearing a device. This treatment would likely be unfeasible for a patient with limited financial means. In addition, he first requires stable glycemic control. (Choice E) Although NPH is sometimes used for basal-bolus insulin, it would not alone provide adequate mealtime insulin coverage. Educational objective: Type 1 diabetes mellitus should be managed with a combination of a longer-acting basal insulin (eg, glargine) and mealtime boluses of a short- or rapid-acting insulin. References: Insulin analogues in type 1 diabetes mellitus: getting better all the time. (http://www.ncbi.nlm.nih.gov/pubmed/28429780)

A 26-Year-Old Man Comes to the Office for a New