Initial management was bedtime insulin glargine; he now uses a multidose insulin regimen of insulin lispro before meals in addition to the glargine. He says that he understands well how to manage his diabetes and is highly motivated to improve self-management but that his current regimen is difficult and he wants to try an insulin pump. He is quite insistent about using a pump as soon as possible. He notes difficulty regularly monitoring his blood glucose and sometimes checks the level only once daily; further, he occasionally misses taking his insulin at work. He is not aware of any recent symptoms of hypoglycemia but thinks that he would recognize symptoms and respond appropriately. His current hemoglobin A1c value is 9.5%.
Which of the following is the most appropriate next step in this patient's anti-hyperglycemic management?
A. Advise him to avoid shift work.
B. Refer him to an endocrinologist for counseling and evaluation.
C. Increase his glargine dosage.
D. Change the current regimen to twice-daily premixed insulin.
E. Prescribe an insulin pump.
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