This patient should decrease his meal-time insulin and continue metformin. He has hypoglycemic unawareness secondary to a diminished counterregulatory response that has developed in the setting of repeated episodes of hypoglycemia. His hypoglycemia occurs in the postprandial state, thus the meal-time insulin should be decreased to allow permissive hyperglycemia for 2 to 3 weeks. Permissive hyperglycemia is defined as allowing an increase in blood glucose values to the level at which no further episodes of hypoglycemia occur. Using less stringent glycemic goals during this period will provide the body an opportunity to reset the counterregulatory response to hypoglycemia to a more appropriate blood glucose range, if possible. Although developing mutual hemoglobin A_1c goals with the patient is important, hypoglycemia in this scenario precludes reaching his goal safely. Once he no longer has hypoglycemia, changes to the meal-time insulin doses or to meal content and volume can be evaluated to fine-tune his regimen while avoiding hypoglycemia.

Continuing the current regimen places the patient at increased risk for continued hypoglycemia in the setting of hypoglycemic unawareness.

Increasing the metformin dose may improve insulin sensitivity and decrease hepatic gluconeogenesis, which could improve the hyperglycemia and/or worsen the hypoglycemia. An increased metformin dose does not address the serious complication of hypoglycemic unawareness, which must be corrected first.

Pramlintide could decrease the hemoglobin A_1c to the patient's goal; however, hypoglycemia is a side effect of pramlintide in conjunction with insulin use. This may further increase the risk of hypoglycemia in this scenario. Pramlintide is an amylin mimetic that decreases glucagon secretion and increases satiety by decreasing gastric emptying. Pramlintide should be considered when the intended reduction in hemoglobin A_1c is modest and the desired effects are a reduction in both weight and postprandial hyperglycemia.