Interactive diabetes case 4: Uncontrolled diabetes in a 51-year-old patient on insulin and two oral agents – A1

Answer — Correct.

Metabolic control is improved but not satisfactory. Fasting and pre-meal glucose values remain very variable. Fasting glucose values range from 77 to 197 mg/dL (4.3 to 10.9 mmol/L) but are mostly in the mid-100s. Values before supper are still often low, in the 40s and 50s, but are in the low 100s on other days. He has reactions in the late afternoon while still at work, but now only once a week. He notes some problem with short-term memory, which you attribute to recurrent hypoglycemia, but is still able to balance his checkbook and function at work. You continue to adjust the doses of NPH insulin over the next few visits, decreasing the morning dose and increasing the evening dose until he is on NPH 14 units before breakfast and 20 units before supper. The patient and his wife learn to count carbohydrates but variability of glucose values persists at all times of day, not readily explained by variations in diet or physical activity. The glycated hemoglobin (A1C) values have risen to the 6.20 to 6.40 percent range.

What do you do now?

●You conclude that the level of metabolic control is satisfactory because the A1C level is excellent and that occasional hypoglycemic reactions are to be expected. You review the symptoms of hypoglycemia and the response to hypoglycemic episodes, encouraging him to avoid overtreatment of hypoglycemia. (See "Interactive diabetes case 4: Uncontrolled diabetes in a 51-year-old patient on insulin and two oral agents – B1".)

●You review the patient's history, again noting the persistent variability of glucose values throughout the day. You order anti-islet antibodies (GAD and IA-2 [glutamic acid decarboxylase and islet antigen 2, respectively] antibodies) and consider the use of an intensive insulin regimen. (See "Interactive diabetes case 4: Uncontrolled diabetes in a 51-year-old patient on insulin and two oral agents – B2".)

●You doubt the patient's story because of persistent variability of glucose values on a regimen of insulin, metformin, and glipizide that appears to be satisfactory. You send him back to the registered dietitian to review carbohydrate counting and advise him to limit his physical activity. (See "Interactive diabetes case 4: Uncontrolled diabetes in a 51-year-old patient on insulin and two oral agents – B3".)

Please note that answer A2 is also correct.

To explore the consequences of the other responses, return to the case at the beginning of this sequence. (See "Interactive diabetes case 4: Uncontrolled diabetes in a 51-year-old patient on insulin and two oral agents".)