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

CASE — A 27-year-old male graduate student is referred by his university health service clinician for management of type 1 diabetes.

At age 12 years, the patient was hospitalized for inability to walk, found to be in diabetic ketoacidosis (DKA), and started on insulin. He has had no other episodes of DKA. He checks his capillary blood glucose level approximately five times a day, but he does not keep a diary. He takes glargine insulin 26 units at 11 PM daily and doses of lispro insulin four times daily. He describes his blood glucose values and lispro insulin doses as shown in the table (table 1).

He reports headaches and weakness with low blood glucose readings almost daily but denies sweating, tremulousness, palpitations, or syncope. These symptoms and low blood glucose values can occur at any time of day depending on food intake and insulin dose. He does not eat breakfast. His first meal of the day, at noon, is typically two sandwiches and a glass of fruit juice. Dinner at 6 PM is typically 3 ounces of meat, a vegetable, soup, and two red bliss potatoes. He snacks frequently and variably in the evenings.

The glycated hemoglobin (A1C) was 5.80 percent six weeks ago and 5.90 percent three months ago. He weighs 160 pounds (72.7 kilograms) with a body mass index (BMI) of 23 kg/m². What is your assessment and plan?

●The patient is in excellent control based on his A1C levels, at which some hypoglycemia is to be expected. Since the symptoms are minimal, you advise him to eat breakfast and caution him about the danger of taking lispro insulin at 7 AM without eating. (See "Interactive diabetes case 3: Hypoglycemia in a patient with type 1 diabetes – A1".)

●The patient may be having frequent episodes of hypoglycemia with hypoglycemia unawareness. He needs to eat breakfast, keep a written diary, and learn to count carbohydrates. You reduce the dose of glargine insulin to 20 units at bedtime and reduce the dose of lispro insulin before lunch to 10 units and the dose of lispro before dinner to 12 units. (See "Interactive diabetes case 3: Hypoglycemia in a patient with type 1 diabetes – A2".)

●His primary issue at age 27 years is cardiovascular disease prevention. He needs a statin, a beta-adrenergic blocking agent, an angiotensin-converting enzyme (ACE) inhibitor, and aspirin. (See "Interactive diabetes case 3: Hypoglycemia in a patient with type 1 diabetes – A3".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Type 1 diabetes (The Basics)" and "Patient education: Using insulin (The Basics)")

●Beyond the Basics topics (see "Patient education: Type 1 diabetes: Overview (Beyond the Basics)" and "Patient education: Glucose monitoring in diabetes (Beyond the Basics)" and "Patient education: Type 1 diabetes: Insulin treatment (Beyond the Basics)")