Interactive diabetes case 3: Hypoglycemia in a patient with type 1 diabetes – A2

ANSWER — Correct.

The patient returns two weeks later with his glucose diary. He has been checking the blood glucose level four to six times daily, with the following results, as shown in the table (table 1).

He has had headaches with most of the low blood glucose values, treated with 8 to 10 ounces of orange juice or other fruit juice. Often, the low blood glucose values are followed by high blood glucose values. He is now eating breakfast, snacking less in the evenings, learning to count carbohydrates, and swimming in the evenings. What is your assessment and plan?

●The reduction in the doses of insulin has not been effective, and it is unsafe to reduce insulin further in a patient with type 1 diabetes. He has to live with the low glucose values to achieve optimal control and prevent the glycated hemoglobin (A1C) values from rising. (See "Interactive diabetes case 3: Hypoglycemia in a patient with type 1 diabetes – B1".)

●The dose of insulin is still excessive. Further reductions are needed to eliminate hypoglycemia and to reverse hypoglycemia unawareness. Also, the patient needs to use less juice (eg, 4 ounces of orange juice or equivalent) to prevent the sequence of hypoglycemia followed by hyperglycemia. (See "Interactive diabetes case 3: Hypoglycemia in a patient with type 1 diabetes – B2".)

●The patient is too tightly controlled, but it is unsafe to reduce insulin doses further. You encourage him to increase carbohydrate intake at each meal by 30 grams and at bedtime by 15 grams. (See "Interactive diabetes case 3: Hypoglycemia in a patient with type 1 diabetes – B3".)