M.M., a 35-year-old, 75-kg, unemployed man, has had type 1 diabetes since the age of 3. As a…

M.M., a 35-year-old, 75-kg, unemployed man, has had type 1 diabetes since the age of 3. As a consequence of the diabetes, he has developed proliferative retinopathy and progressive diabetic nephropathy (current SCr, 2.2 mg/dL). M.M. has an erratic lifestyle. Because he does not work, he often stays out late at night and sleeps late into the morning. His insulin is injected whenever he awakens, and his meals are irregularly spaced. Each time he comes to the clinic, he brings with him a complete log of glucose concentrations that range from 80 to 140 mg/dL. He has two to three severe hypoglycemic reactions a month that require trips to the emergency department for treatment with IV glucose. On several occasions, his BG concentration has been 30 mg/dL, and he states he may feel a little weak, but otherwise feels “not too bad.” M.M.’s last A1C was 10%. He says that he adheres to the following insulin regimen: 18 units NPH/11 units regular insulin before breakfast, 10 units regular insulin before lunch and dinner, and 14 units NPH at bedtime. At this visit, M.M. comes with his girlfriend. He has a large gash on his nose that occurred 3 days ago when he lost consciousness at approximately 1:30 PM while pushing his stalled car. He was unable to eat lunch at the usual hour because he had problems with his car. Assess M.M.’s hypoglycemic reactions and BG control. Should his current insulin regimen be continued? How should he be managed?