The most appropriate next step in management of this patient is to decrease the risk of hypoglycemia by decreasing the insulin doses delivered by the pump. This patient has had type 1 diabetes for 25 years with subsequent development of advanced microvascular disease. His frequent hypoglycemic events and hypoglycemic unawareness increase the risk of morbidity and mortality from recurrent hypoglycemia that may occur with stringent glycemic goals. Glycemic goals should be individualized to account for patient-specific factors, such as age and comorbidities. The American Diabetes Association suggests a hemoglobin A_1c goal of less than 8.0% in patients with a decreased life expectancy, history of severe hypoglycemia, multiple comorbidities, or advanced microvascular or macrovascular disease. The less stringent hemoglobin A_1c goal should be implemented to avoid recurrent hypoglycemia; however, the goal may need to be increased above 8.0% if it cannot be achieved safely.

Altering the pump settings to deliver more insulin to attain a hemoglobin A_1c goal of less than 7.0% will increase his risk of hypoglycemia. His hemoglobin A_1c goal should be liberalized to avoid hypoglycemia.

The risk of hypoglycemia can be reduced with lower insulin doses delivered by either an insulin pump or subcutaneous injections. Since the patient is already using an insulin pump, alteration of his insulin pump settings to deliver less insulin should occur next.

Gabapentin for treatment of his painful peripheral neuropathy is appropriate, but avoidance of recurrent hypoglycemia is the most serious issue that needs to be addressed next due to the associated increased risk of morbidity and mortality.