Interactive diabetes case 4: Uncontrolled diabetes in a 51-year-old patient on insulin and two oral agents – A2

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 dinner are still often low, in the 40s and 50s, but are in the low to mid-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 but is still able to balance his checkbook and function at work.

The tests for islet cell antibodies return strongly positive. The anti-GAD antibody level is 0.645, and the anti-IA2 antibody level is 2.132 (reference value is <0.1 for each test). You change the diagnosis to latent autoimmune diabetes in adults (LADA). (See "Interactive diabetes case 4: Uncontrolled diabetes in a 51-year-old patient on insulin and two oral agents – Comment".)

You convert the patient to an intensive insulin regimen, prescribing NPH insulin before breakfast and at bedtime and lispro insulin before breakfast and supper. The doses are adjusted at each visit in response to the patient's history and glucose diary. You stop glipizide because oral insulin secretagogues (sulfonylureas or glinides) are not indicated in patients who are treated with insulin. After several more visits, the patient is well controlled on the following doses: NPH insulin 12 units before breakfast and 22 units at 10 PM, and lispro insulin 5 to 6 units before breakfast and 6 to 10 units before supper. He adjusts his pre-meal doses based on the pre-meal blood glucose level and the estimated carbohydrate content of the meal. An approach to estimating the dose of short- and very short-acting insulins can be found elsewhere. (See "Interactive diabetes case 3: Hypoglycemia in a patient with type 1 diabetes – B2".)

Please note that answer A1 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".)