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

CASE — A 51-year-old construction worker seeks your advice because of frequent hypoglycemic reactions.

Three years ago, the patient was diagnosed with type 2 diabetes following six months of polyuria, blurred vision, and weight loss. He had lost 40 pounds, from 225 to 185 pounds. He was treated with metformin 1000 mg by mouth twice a day. The blood glucose values on treatment improved from the low 300s to the low 200s, and he regained approximately 10 pounds of weight.

Approximately one year ago, the blood glucose values rose to the mid-200s, the patient was tired all the time, and his weight fell again, this time to 180 pounds. Nine months ago, glipizide 5 mg by mouth every morning before breakfast was added to his regimen with no improvement in the blood glucose levels. Six months ago, the dose of glipizide was increased to 10 mg before breakfast and, two weeks later, to 10 mg before breakfast and supper, again with no improvement in metabolic control.

Four months ago, NPH insulin was added, initially 10 units twice a day, before breakfast and supper, with progressive increases in dose to 35 units before breakfast and 10 units before supper. His weight increased again, this time to 210 pounds. He is checking his blood glucose levels twice daily, before each of his doses of NPH insulin. You review his glucose diary. The glucose values are variable. Before breakfast, the glucose values range from 130 to 240 mg/dL (7.2 to 13.3 mmol/L); before supper, the values are 60 to 90 mg/dL (3.3 to 5 mmol/L), occasionally just over 100 mg/dL (5.6 mmol/L). He has symptoms of hypoglycemia approximately three times a week, between 11 AM and noon, usually related to omission of his morning snack and increased physical activity at work. (He is also very active on weekends, playing and teaching hockey.) Occasionally he also has a reaction in the afternoon at work. Two months ago, he had a severe reaction at work with loss of consciousness in the afternoon.

The patient eats three meals a day with snacks in the midmorning and at 2 PM. He saw a registered dietitian and was advised to control portion size and avoid concentrated sweets. He did not learn how to count carbohydrates. The glycated hemoglobin (A1C) was 8.80 percent four months ago and 5.9 percent one month ago. The patient's weight is 210 pounds, and at 5' 7", his body mass index (BMI) is 33 kg/m². He has hypertension treated with lisinopril 20 mg every morning and hypercholesterolemia treated with atorvastatin 10 mg by mouth every evening. His mother, age 85 years, has had type 2 diabetes since her late 70s.

What is your assessment and plan?

●You decide that the patient probably has type 2 diabetes based on his clinical presentation, the positive family history of type 2 diabetes, and the presence of other features of the metabolic syndrome, including obesity, hypertension, and hypercholesterolemia. You advise him to adjust his insulin to reflect his glucose values. You decrease the morning dose of NPH to 25 units to reduce or eliminate afternoon hypoglycemia, increase the evening dose of NPH to 14 units before supper to control the morning hyperglycemia, explain the benefits of counting carbohydrates, and refer him to a registered dietitian. You anticipate the need for further adjustments in the doses of insulin. (See "Interactive diabetes case 4: Uncontrolled diabetes in a 51-year-old patient on insulin and two oral agents – A1".)

●You conclude that the variability of blood glucose values and the occurrence of hypoglycemia late in the day on small doses of insulin for a patient with type 2 diabetes raise the possibility of latent autoimmune diabetes in adults (LADA). You advise him to adjust his insulin to reflect his glucose values. You decrease the morning dose of NPH to 25 units to reduce or eliminate afternoon hypoglycemia, increase the evening dose of NPH to 14 units before supper to control the morning hyperglycemia, explain the benefits of counting carbohydrates, and refer him to a registered dietitian. You anticipate the need for further adjustments in the doses of insulin. You order anti-islet antibodies (GAD and IA-2 [glutamic acid decarboxylase and islet antigen 2, respectively] antibodies). (See "Interactive diabetes case 4: Uncontrolled diabetes in a 51-year-old patient on insulin and two oral agents – A2".)

●You decide that the patient probably has type 2 diabetes based on his clinical presentation, the positive family history of type 2 diabetes, and the presence of other features of the metabolic syndrome, including obesity, hypertension, and hypercholesterolemia. You advise him to increase his caloric intake at lunch and in the afternoon to reduce or eliminate hypoglycemia late in the day. (See "Interactive diabetes case 4: Uncontrolled diabetes in a 51-year-old patient on insulin and two oral agents – A3".)

●You decide that the patient probably has type 2 diabetes based on his clinical presentation, the positive family history of type 2 diabetes, and the presence of other features of the metabolic syndrome, including obesity, hypertension, and hypercholesterolemia. In view of the variability of his glucose values before breakfast, you advise him to use a sliding scale for the morning NPH insulin dose, as follows: for glucose of less than or equal to 100 mg/dL, take 20 units; for glucose of 101 to 200, take NPH 25 units; for glucose of 201 to 300, take 35 units. You do not change the afternoon dose of insulin. You explain the benefits of counting carbohydrates and refer him to a registered dietitian. (See "Interactive diabetes case 4: Uncontrolled diabetes in a 51-year-old patient on insulin and two oral agents – A4".)