A glycemic management nurse practitioner was consulted on a patient, aged 67 years, who was hospitalized following lumbar spine surgery on postoperative day two. The patient had a history of uncontrolled type 2 diabetes mellitus and was on four different injectable antihyperglycemic agents at home.

The patient was diagnosed with type 2 diabetes mellitus (T2DM) twenty years ago. His diabetes was complicated by diabetic retinopathy and diabetic nephropathy. His other comorbidities include obesity (Class I), obstructive sleep apnea, hypertension, hyperlipidemia, and gastroesophageal reflux disease (GERD).

The patient’s home medications included:

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  • Insulin detemir (Levemir) 65 units subcutaneous at bedtime
  • Insulin aspart protamine suspension 70%, insulin aspart 30% (NovoLog Mix 70/30) 40 units subcutaneous three times daily
  • Insulin aspart (Novolog) 15 units subcutaneous three times daily with each meal
  • Liraglutide (Victoza) 1.8 mcg subcutaneous daily
  • Aspirin 81 mg by mouth daily
  • Losartan 100 mg daily
  • Hydrochlorothiazide 25 mg by mouth daily

The patient’s antihyperglycemic regimen was started by an endocrinologist 5 years ago. He had not returned for an endocrine follow-up appointment for 2 years. His internist refilled diabetes-related prescriptions.

The patient stated he routinely performed twice to three times daily glucose self-monitoring at home and reported a history of hypoglycemia unawareness with rare occasions of asymptomatic glucoses in the 40 to 50 mg/dL range (once every few months). Otherwise, glucoses were in the 200 to 300 mg/dL range.