7/3/2016

Casesillustratingproblemswithinsulintherapyfordiabetesmellitus

Casesillustratingproblemswithinsulintherapyfordiabetesmellitus

Contributordisclosures
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:May2016.|Thistopiclastupdated:Jun10,2015.
INTRODUCTIONThefollowingcasesillustratesomeofthecommonproblemsthatmayariseduringintensive
insulintherapyinpatientswithtype1diabetesmellitus.(See"Managementofbloodglucoseinadultswithtype1
diabetesmellitus".)
LACKOFCONTROLDUETODIETA57yearoldhospitaladministratorwhohashadtype1diabetesfor15years
istryingveryhardtomaintainstrictglycemiccontrol.Shekeepsfitwithexercise,andadjustsnotonlyherinsulindose
butalsoherfoodintakeandexercisepatterninresponsetoherbloodglucoseconcentrations.
Herusualinsulindosesare:

Beforebreakfast6unitsregularinsulinand26unitsNPHinsulin
Beforelunch4unitsregularinsulin
Beforeeveningmeal4unitsregularinsulin
Beforebedtime26unitsNPHinsulin

Sheisfrustratedattheunpredictabilityofherbloodglucosevalues,asshownbelow(inmg/dLand,in
parentheses,mmol/L).
DayBeforeBeforeBeforeBefore
breakfastluncheveningmealbedtime
1195(10.8)52(2.9)126(7.0)88(4.9)
261(3.4)46(2.6)210(11.7)197(10.9)
3287(15.9)222(12.3)161(8.9)72(4.0)
InterpretationandapproachThispatientisprobablytryingtoohard.Ifapersoncontinuallyadjustsinsulindoses,
foodintake,andexercise,itisoftenimpossibletoidentifypatternsthatcanbecorrected.Inthiswoman,keepinga
threedayfoodrecordcandetermineiftherearemajorproblemswithdietaryinconsistency(figure1).Ascanbeseen,
thewoman'stotalcarbohydrateintakeanditsdistributionaremarkedlydifferenteachday.Thisvariabilitypreventsthe
attainmentofstrictglycemiccontrolwithanintensiveinsulinregimen.
Youcanattempttocorrectthedietaryinconsistencybyadvisinghertoconsultanutritionistortoattendadiet
workshop,whichcanbesetupfor6to10patientsatatime[1].Attheseworkshops,approximately10to12meals
arelaidout,includingbreakfasts,fastfoodlunches,fancyeveningmeals,andsnacks.Patientsareaskedtoestimate
howmanygramsofcarbohydrateareineachmeal.Their(andclinicians')estimatesareoftenremarkablyinaccurate,
butcanimprovewithtraining.Oncethishasbeenachieved,itisthenpossibletodevelopaConsistentCarbohydrate
Profileforeachpatient.Thepatientcanquotethisprofiletoyouateveryclinicvisitand,moreimportantly,itbecomes
partoftheirconsciousbehavioratmealtimes.Ratherthanforcingapatienttoeatthesameamountofcarbohydrate
atthesamemealeverydaywithafixeddoseofinsulin,somepatientscanbetaughttocalculatea
carbohydrate:insulinratio.Asanexample,thispatientmayneed1unitofregularinsulintocover15gofcarbohydrate.
Althoughshetypicallyeats90gofcarbohydrateforbreakfast(andsotakes6unitsofregularinsulin),ifsheateonly
30gononemorning,shewouldreduceherregularinsulindoseto2units.Shemightthenuseaninsulinalgorithmto
adjustthisbasicdosebasedonherbloodglucoseconcentration(seebelow).
BEDTIMEHYPERGLYCEMIAA27yearoldwomanwithtype1diabetesistreatedwiththefollowingregimen:
Beforebreakfast8unitsinsulinaspartand20unitsinsulindetemir
Beforeeveningmeal4unitsaspart
Beforebedtime12unitsdetemir
Herbloodglucosevalues(inmg/dLand,inparentheses,mmol/L)areasfollows:
DayBeforeBeforeBeforeBefore
breakfastluncheveningmealbedtime
http://www.uptodate.com.scihub.bz/contents/casesillustratingproblemswithinsulintherapyfordiabetesmellitus?source=search_result&search= 1/7

7/3/2016

Casesillustratingproblemswithinsulintherapyfordiabetesmellitus

186(4.8)104(5.8)96(5.3)320(17.8)
2146(8.1)123(6.8)105(5.8)296(16.4)
3111(6.2)97(5.4)92(5.1)341(18.9)
InterpretationandapproachThemainproblemwithhercurrentlevelofglycemiccontrolishyperglycemiabefore
bedtime.Thiscanprobablybeimprovedbyincreasingthedoseofinsulinaspartbeforehereveningmeal.Itisalso
prudenttoconsidersomeotheraspectsofherlifestyle.Asanexample,shemaybeeatinghereveningmealverylate,
sothatthereisnotmuchtimebetweenthemealandherbedtimetest.Furthermore,theeveningmealmaybeher
biggestmealoftheday.Itwouldthereforebehelpfultoreviewherfoodrecordtoseehowshedistributesherfood
andwhattypeoffoodsheiseating.
MORNINGHYPERGLYCEMIAA24yearoldinsurancesalesmanwithtype1diabetesfortwoyearsfeelsstressed
andtiredatworkandhasearlymorningheadaches.Hisglycatedhemoglobin(A1C)valueis9.6percent.Untilfairly
recently,hethoughtthathisdiabeteswaswellcontrolled.Hiscurrentregimenis:
Beforebreakfast6unitsregularinsulinand28unitsNPHinsulin
Beforeeveningmeal4unitsregularinsulinand16unitsNPHinsulin
Bloodglucosevalues(inmg/dLand,inparentheses,mmol/L)are:
DayBeforeBeforeBeforeBeforeBefore
breakfastlunchsnackeveningmealbedtime
(8AM)(12PM)(1:30PM)(5PM)(11PM)
1282(15.7)140(7.8)261(14.5)82(4.6)130(7.3)
2321(17.8)163(9.1)294(16.3)96(5.3)123(6.8)
3280(15.6)153(8.5)310(17.2)107(5.9)144(8.0)
InterpretationandapproachTheincreasingdifficultyinmaintainingglycemiccontrolinthispatientwithrecent
onsetdiabetesisprobablydueinparttoaprogressivedeclineinendogenousinsulinsecretion.Inaddition,hisinsulin
regimenisnotideal:heistakingtoolittleregularinsulinandtoomuchNPHinsulin.Asanexample,hishighblood
glucosevaluesat1:30PMsuggestthatheneedstotakeregularinsulinbeforelunch.
Ontheotherhand,thetriadofreasonablebloodglucosevaluesbeforebedtime,veryhighfastingvaluesbefore
breakfast,andahistoryoftirednessandearlymorningheadachesuggestaproblemwiththeNPHinsulindosethat
heistakingbeforehiseveningmeal.TheactionoftheNPHinsulinmaybemaximalinthelateeveningandmiddleof
thenight(causingbothnormoglycemiaatbedtimeandnocturnalhypoglycemia)andthendissipatingintheearly
morning(causinghyperglycemiabeforebreakfast)[2].
Thehypothesisthatnocturnalhypoglycemialeadstofatigueanddecreasedwellbeingwastestedinastudyof10
patientswithtype1diabeteswhowereevaluatedonthemorningafterexperimentallyinducednocturnal
hypoglycemia(foronehourat41mg/dL[2.3mM])andonacontrolnightwhenhypoglycemiawasavoided[3].
Symptomsofwellbeingandfatigueweresignificantlyworseafterthenightofhypoglycemia,althoughhighercerebral
functionwasunchanged.
Thepresenceofnocturnalhypoglycemiafollowedbyearlymorninghyperglycemiacanbeconfirmedbymeasuring
bloodglucoseat3AM.OnesolutionistomovehiseveningdoseofNPHinsulinfrombeforetheeveningmealto
beforebedtime.AnotherapproachmightbetoswitchfromNPHinsulintoaninsulinwithalonger,flatterprofile(such
asinsulinglargineordetemir).Inaddition,otheraspectsofhislifestyleshouldalsobeevaluated:
Hemaynotbeeatingenoughcarbohydrateinhiseveningmealorlatenightsnack.
Alternatively,thetypeoffoodheiseatingmaybeinadequatetomaintainhisbloodglucoseconcentration
throughthenight.Abedtimesnackthatislowinprotein,fat,andfibermaybeentirelydigestedandabsorbed
withintwoorthreehours.
Areviewofhisexercisepatternsintheeveningmayalsobehelpful.Vigorousexerciseatthattimemakesit
morelikelythathisbloodglucoseconcentrationwillfalltolowvaluesduringthenight.
Thefollowingchangesinhisinsulinregimenleadtomarkedimprovementinhisglycemiccontrol:
8unitsinsulinglulisineand30unitsinsulinglarginebeforebreakfast
6unitsglulisinebeforelunch
http://www.uptodate.com.scihub.bz/contents/casesillustratingproblemswithinsulintherapyfordiabetesmellitus?source=search_result&search= 2/7

7/3/2016

Casesillustratingproblemswithinsulintherapyfordiabetesmellitus

8unitsglulisinebeforetheeveningmeal
Threemonthslaterhisbloodglucosevalues(inmg/dLand,inparentheses,mmol/L)are:
DayBeforeBeforeBeforeBeforeBefore3AM
breakfastlunchsnackeveningmealbedtime
1141(7.7)110(6.2)161(8.9)82(4.6)140(7.8)92(5.1)
2121(6.7)163(9.1)134(7.4)96(5.3)93(5.2)
3150(8.3)153(8.5)110(6.2)107(5.9)144(8.0)104(5.9)
HisA1Cvalueisnow7.8percent.Hehasmoreenergy,theheadachesaregone,heiseatingandexercising
consistently,andhasjustbeenpromotedbecauseofhisimprovedproductivity.ToreducehisA1Cvaluetobelow7.0
percent,hewillprobablyrequireapremealinsulinalgorithm.(See"Bloodglucoseselfmonitoringinmanagementof
adultswithdiabetesmellitus".)
INSULINALGORITHMA43yearoldfactoryworkerisstrivingforstrictglycemiccontrolwiththreeinjectionsof
insulinperday.Herbloodglucoseconcentrationsaresomewhatvariableduetoalterationsinherfoodintakeand
exerciseprogram.Sheisinterestedinusinganinsulinalgorithm.Hercurrentregimenconsistsof:
Beforebreakfast8unitsregularinsulinand15unitsNPHinsulin
Beforedinner7unitsregularinsulin
Beforebedtime8unitsNPHinsulin
Herbloodglucosevalues(inmg/dLand,inparentheses,mmol/L)areasfollows:
DayBeforeBeforeBeforeBefore
breakfastluncheveningmealbedtime
1159(8.8)134(7.4)186(10.3)84(4.7)
2117(6.5)164(9.1)210(11.7)97(5.4)
3102(5.7)122(6.8)261(14.5)79(4.4)
InterpretationandapproachHerbloodglucoseconcentrationsvarybeforebreakfast,lunch,andherevening
meal(dinner).Sheshouldthereforeadjustherdosesofregularinsulinaccordingtoaninsulinalgorithm(table1).The
algorithmisdesignedspecificallyforeachpatient.Differentpatientsvaryinhowmuchtheinsulindosesneedtobe
changedandwhatbloodglucosevalueswillbeusedtoguidethechanges.Somepatients,asanexample,need
muchsmalleradjustmentsthanothers.(See'Latemorninghyperglycemia'below.)
Sheshouldnottakeextrainsulinbeforebedtime,andshouldnotadjustherdosesofNPHinsulin.
Ifthisalgorithmwereappliedtohercurrentinsulinregimen,thenthealterationsinherdoseofregularinsulinonday1
accordingtothebloodglucoseconcentrationwouldbe:
Day1:

Beforebreakfast159mg/dL(8.8mmol/L)add1unitregularinsulintototaldoseof9units
Beforelunch134mg/dL(7.4mmol/L)noinsulindose
Beforedinner186mg/dL(10.3mmol/L)add2unitsregularinsulintototaldoseof9units
Beforebedtime84mg/dL(4.7mmol/L)nochange

Similaradjustmentswouldbemadeonsubsequentdaysuntilglycemiccontrolisattained.Shecouldalsoconsider
usingacarbohydrate:insulinratiotoallowhertotakelessfoodandlessinsulinatcertainmeals.
VARIABLEGLYCEMICCONTROLA32yearoldexecutivehasabusyofficejobthatisunpredictableintermsof
physicalactivity,timeofmeals,orthelengthoftheworkday.Hercurrentinsulinregimenis:
Beforebreakfast4unitsregularinsulinand10unitsNPHinsulin
Beforeeveningmeal8unitsregularinsulinand14unitsNPHinsulin
Herbloodglucoserecords(inmg/dLor,inparentheses,inmmol/L)foroneweekareasfollows.Theasteriskrefersto
hypoglycemicepisodesandAreferstoaveragevaluesduringtheweek.
DayBeforeBeforeBeforeBefore3AM
breakfastluncheveningmealbedtime
http://www.uptodate.com.scihub.bz/contents/casesillustratingproblemswithinsulintherapyfordiabetesmellitus?source=search_result&search= 3/7

7/3/2016

Casesillustratingproblemswithinsulintherapyfordiabetesmellitus

1156(8.7)111(6.2)97(5.4)63(3.5)
2147(8.2)98(5.4)59*(3.3)301(16.7)
3182(10.1)124(7.9)86(4.8)87(4.7)91(5.1)
4191(10.6)115(6.4)46*(2.6)62(3.4)
5165(9.3)108(6.0)101(5.6)235(13.1)
6246(13.7)89(4.9)92(5.1)57(3.3)78(4.3)
7178(9.9)97(5.4)67(3.7)164(9.1)
A181(10.1)106(5.9)78(4.3)138(7.7)
Sheplayedracquetballforonehourat8PMonday4andhadalatenightpizzaat11PMonday5.
InterpretationandapproachEvaluationofthispatient'srecordscanbebestapproachedbyconsideringeach
timeperiodseparately:
BeforebreakfastHeraveragebloodglucosevaluebeforebreakfastistoohighat181mg/dL(10.1mmol/L).The
individualvaluesarealsofairlyconsistent(from147to191mg/dL[8.2to10.6mmol/L])apartfromonehighvalue
(246mg/dL[13.7mmol/L])onday5,whichcanprobablybeexplainedbyherlatenightpizzatheprecedingday[4].
ThispatientshouldbenefitfromincreasingherNPHinsulindosebeforetheeveningmeal,sincethisisthe
insulinthatisworkingduringthenight.However,hertwo3AMvaluesareintheidealrange.Thereisthereforea
riskthatincreasinghereveningNPHinsulindosewillinducenocturnalhypoglycemia.Thisriskcanbeminimized
byincreasinghereveningNPHinsulininsmallincrementsandcontinuingtomeasurebloodglucosebothat3
AMandbeforebreakfast.AnotherapproachistohavehertakehereveningdoseofNPHinsulinatbedtime,
insteadofbeforetheeveningmeal.Shecouldalsobeswitchedtoinsulindetemirorinsulinglargine.
BeforelunchHerbeforelunchbloodglucosevaluesareconsistentandaverage106mg/dL(5.9mmol/L).Thisis
verygoodcontrol,suggestingthathermorningdoseofregularinsulinandherbreakfastandmidmorningsnacks
areappropriateandconsistentfromdaytodayandthatherexerciseandworkscheduleforthemorningare
relativelyconstant.However,shemaybeindangerofhypoglycemiabeforelunchonceherbeforebreakfast
glucosevaluesareloweredasrecommendedabove.Itmightthereforebewisetoslightlydecreasehermorning
regularinsulindoseastheeveningNPHinsulindoseisincreased.
BeforeeveningmealHerbeforeeveningmealbloodglucosevaluesaretoolow,withanaveragevalueof
78mg/dL(4.3mmol/L)andtwohypoglycemicepisodesduringtheweek.Thesefindingssuggestthatshemaybe
takingtoomuchNPHinsulinbeforebreakfast,sincethisistheinsulinthatisactingduringtheafternoon.Another
possibleexplanationmightbethatherlunchistooearlyortoolight,orthatshedoesn'teatanadequatemid
afternoonsnack.Thereisinadequateinformationtoidentifytheprimaryproblem.
BeforebedtimeHerbeforebedtimebloodglucosevaluesaverage138mg/dL(7.7mmol/L).Whilethisaverageis
closetoideal,theindividualvaluesvarywidelyfrom57to301mg/dL(3.2to16.7mmol/L).Thissuggeststhat
somevariableaspectofherlifestyleiscreatingthefluctuationsinthebedtimeglucosevalues.Possible
problemsincludevariationinthetimeorcontentofhereveningmealorineveningexercise.Asanexample,the
bloodglucosevalueof301mg/dL(16.7mmol/L)beforebedtimeonday2mayhaveresultedfromdietary
overcompensationforherhypoglycemicepisodebeforetheeveningmeal.
Insummary,thispatient'srecordkeepingisbetterthanmost.Nevertheless,itisnotsufficienttopermitassessmentof
herproblemsbeforetheeveningmealandbeforebedtime.Itwouldbehelpfultoknowtheexacttimeswhenherblood
glucosewasmeasuredandexactlywhensheeatsandthecontentofeachmeal.
LATEAFTERNOONHYPOGLYCEMIAA42yearoldgaragemechanicistreatedwiththefollowinginsulin
regimen:
Beforebreakfast8unitsinsulinlisproand16unitsinsulinglargine
Beforelunch4unitslispro
Beforeeveningmeal10unitslisproand22unitsglargine
Heusesanalgorithm(table2)toadjustpremealdosesoflisproinsulin.
Bloodglucosevalues(inmg/dLor,inparentheses,mmol/L)foroneweekareshownbelow.Thedosesoflispro(LP)and
glargine(G)insulinarealsonoted.Theasterisksondays2and4reflecthypoglycemicepisodes.
DayBeforeBeforeBeforeBefore3AM
breakfastluncheveningmealbedtime
http://www.uptodate.com.scihub.bz/contents/casesillustratingproblemswithinsulintherapyfordiabetesmellitus?source=search_result&search= 4/7

7/3/2016

Casesillustratingproblemswithinsulintherapyfordiabetesmellitus

1100(5.6)205(11.4)116(6.4)115(6.4)
8LP,16G8LP10LP,22G
2118(6.6)172(9.6)47*(2.6)124(6.9)92(5.1)
8LP,16G7LP8LP,22G
377(4.3)145(8.1)85(4.7)108(6.0)
6LP,16G4LP10LP,22G
4113(6.3)136(7.6)54*(3.0)111(6.2)
8LP,16G5LP8LP,22G
5132(7.3)97(5.4)103(5.7)97(5.4)87(4.8)
9LP,16G4LP10LP,22G
698(5.4)122(6.8)82(4.6)102(5.7)
8LP,16G5LP10LP,22G
7158(8.8)109(6.1)93(5.2)89(4.9)
8LP,16G4LP10LP,22G
9:55AM(late)
A114(6.3)141(7.8)83(4.6)107(5.9)
InterpretationandapproachThispatient'srecordisquitecomplete,butthereisnoinformationaboutthequantity
offoodeatenandperiodsofexercise.Heisconsistentaboutthetimingofbloodglucosetestingandmealsandhas
adjustedhisinsulindosescorrectlyusingthealgorithm.Hemadeonlyone"mistake."Hisbloodglucosewas
measuredbetween7:05and7:15AMeverydayexceptfordaysevenwhenhesleptlateandthetestwasdoneat
9:55AM.Accordingtothealgorithm,heshouldhaveincreasedthedoseoflisproinsulinby2to10unitsforablood
glucosevalueof158mg/dL(8.8mmol/L).Severalotherpatternscanbedetected:
Heneededtotakeextrainsulinbeforelunchonfourofthesevendays.Thissuggeststhathisprebreakfast
doseoflisproinsulinmaybetooloworthathismidmorningsnackistoolargeortakentooclosetolunch.
Hisaveragebloodglucosevalueistoolow(83mg/dL[4.6mmol/L])beforetheeveningmeal,withhypoglycemia
occurringondaystwoandfour.Possibleexplanationsincludeamorningdoseofinsulinglargineorlunchtime
doseoflisproinsulinthatistoohigh,oraninadequatemidafternoonsnack.
Hisbloodglucosevaluesbeforebedtimeandat3AMarenormal.
LATEMORNINGHYPERGLYCEMIAA21yearoldwomanis62inches(157cm)tallandweighs104lb(47kg).
Sheruns40milesperweek.Sheisbeingtreatedwithacontinuoussubcutaneousinsulininfusion(CSII)accordingto
thefollowinginsulinregimen.(See"Managementofbloodglucoseinadultswithtype1diabetesmellitus".)

Basalinfusionrate0.4units/hour
Prebreakfastbolusdose3units
Prelunchtimebolusdose2units
Preeveningmealbolusdose4units

Sheadjuststhepremealbolusdosesaccordingtothefollowingalgorithm(table3).
Shehaskeptathreedayrecordofherglycemiccontrol,withthedosesofregularinsulinshownundertheblood
glucosevalues(inmg/dLand,inparentheses,mmol/L).Thetimeofthepremealmeasurementsisroughlyconstant
fromdaytoday.
DayBeforeBeforeBeforeBefore3AM
breakfastluncheveningmealbedtime
1105(5.8)195(10.8)146(8.1)125(6.9)
3units3.5units5units
2112(6.2)122(6.8)147(8.2)94(5.2)89(4.9)
3units2.5units5units
377(4.3)186(10.3)165(9.2)108(6.0)
2units3.5units5.5units
http://www.uptodate.com.scihub.bz/contents/casesillustratingproblemswithinsulintherapyfordiabetesmellitus?source=search_result&search= 5/7

7/3/2016

Casesillustratingproblemswithinsulintherapyfordiabetesmellitus

InterpretationandapproachThispatient'srecordsarecompletewithregardtotime,bloodglucosevalues,and
insulindoses.Sheisconsistentintermsofbloodglucosetestingandtimingofmeals,butwedonothaveinformation
aboutthesizeandnumberofmealsorthetimingofexercise.Thisconsistencyisreflectedintherelativelyconstant
bloodglucoselevelsateachtimeofday.Sheisappropriatelyincreasingherbeforelunchandbeforeeveningmeal
bolusinsulindoses,sinceherbloodglucosevaluesareelevatedonlyatthosetimes.Thefactthatshehastoadd
insulineverydaybeforelunchsuggeststhatsomeadjustmentmaybeneededinheroverallregimenduringthe
morning.Shemayneedalargerprebreakfastdoseofinsulin,asmallerbreakfastormidmorningsnack,oran
increaseinherbasalrateofinsulininfusion.Shecouldalsoconsiderusingacarbohydrate:insulinratiotoallowherto
takelessfoodandlessinsulinatcertainmeals.Itwouldalsohelpifsheswitchedfromusingregularinsulintoinsulin
aspartinherpump.
EVENINGHYPERGLYCEMIAA34yearoldteacherisstrivingforexcellentglycemiccontrol.Heeatsahealthy
diet,countscarbohydrates,exercisesataconsistenttimeeachday,andhasbeentakingthefollowingregimen:
Beforebreakfast(6AM)4unitsinsulinaspartand14unitsNPH
Beforelunch4unitsinsulinaspart
Beforeeveningmeal(6PM)6unitsinsulinaspartand14unitsNPHinsulin
Dosesofinsulinaspartarealsoadjustedusinganinsulinalgorithm.
Becauseofnocturnalhypoglycemiaandunexplainedvariationinbloodglucoseconcentrationsbeforetheevening
meal,NPHinsulinwasstoppedandreplacedwithasingledoseof28unitsinsulinglarginetakenat10PM.Doses
ofinsulinaspartremainedthesame.Typicalbloodglucoseconcentrations(inmg/dLand,inparentheses,mmol/L)afew
weekslaterare:
DayBeforeBeforeBeforeBefore
breakfastluncheveningmealbed
(6AM)(11AM)(6PM)(10PM)
1107(5.9)123(6.8)163(9.1)296(16.4)
2130(7.3)111(6.2)146(8.1)210(11.7)
3140(7.8)144(8.0)178(9.9)261(14.5)
InterpretationandapproachBloodglucosevaluesareidealbeforebreakfastandlunch,butaresomewhathigh
beforetheeveningmealandaremuchtoohighbeforebedtime.Sincehehasnotchangedhiseatinghabitsordoses
ofinsulinaspart,itislikelythattheeffectoftheinsulinglargineiswaningafter20hours.Hecouldtryincreasingthe
doseofinsulinglargineorsplittingitintotwoequaldosestakenabout12hoursapart.Alternatively,hecouldincrease
thedoseofinsulinaspartbeforetheeveningmeal.
SWITCHINGFROMNPHINSULINTOINSULINDETEMIRA33yearoldmanwithtype1diabetesistreatedwith
thefollowingregimen:
Beforebreakfast28unitsNPHinsulin
Beforebedtime12unitsNPHinsulin
Healsoadministersinsulinaspartbyslidingscalebeforeeachmeal.
Despitebeingextremelyconsistentfromdaytodayinhisactivitylevelandinthetimingandcarbohydratecontentof
hismeals,heishavingunpredictableswingsinbloodglucoseconcentrationswithoccasionalepisodesof
hypoglycemiainthelatemorningorearlyafternoon.
Bloodglucosevalues(inmg/dLand,inparentheses,mmol/L)are:
DayBeforeBeforeBeforeBefore
breakfastluncheveningmealbed
(8AM)(12PM)(5PM)(11PM)
1132(7.3)54(3.0)*206(11.4)118(6.6)
2119(6.6)136(7.6)140(7.8)151(8.4)
3141(7.8)108(6.0)125(6.9)107(5.9)
4108(6.0)48(2.7)*196(10.9)140(7.8)
*Representepisodesofsymptomatichypoglycemia.

http://www.uptodate.com.scihub.bz/contents/casesillustratingproblemswithinsulintherapyfordiabetesmellitus?source=search_result&search= 6/7

7/3/2016

Casesillustratingproblemswithinsulintherapyfordiabetesmellitus

InordertochangefromNPHtoinsulindetemirhistotaldailydoseofNPHiscalculated(28+12=40),decreasedby
10percent(4units),andisgivenasasingleinjectionof36unitsofdetemirinsulinatbedtime.
Oneweeklaterhisbloodglucosevalues(inmg/dLand,inparentheses,mmol/L)are:
DayBeforeBeforeBeforeBefore
breakfastluncheveningmealbed
(8AM)(12PM)(5PM)(11PM)
198(5.4)124(6.9)*168(9.3)213(11.8)
2103(5.7)131(7.3)171(9.5)232(12.9)
3217(12.1)*127(7.0)192(10.7)251(13.9)
492(5.1)119(6.6)*185(10.3)211(11.7)
*Hewasawakenedwithhypoglycemiaat4AMandtook60gramsofcarbohydratetotreatthis.
InterpretationandapproachHisbloodglucosevaluesbeforebreakfastondays1,2and4areslightlylow.That,
alongwithoneepisodeofhypoglycemiaat4AM,suggeststhat36unitsofinsulindetemirmaybetoomuchforhim.
Thebloodglucosevaluesbeforelunchareideal,buttheyaretoohighbeforedinnerandevenhigherbeforebedtime.
Thissuggeststhatinsulindetemirisnotlasting24hours,butthatitsactionwanesafter18to20hours.Afterswitching
to20unitsinsulindetemirtwicedaily(atabout8AMand8PM)hisbloodglucosevaluesbecamestablethroughout
theday.
Whilemanypatientsdowellwithasingledoseofinsulindetemiratbedtime,thiscaseillustratestwopracticalpoints.
AlthoughitspeakactionislessthanthatofNPHinsulin,itcanhaveaslightpeakinsomepatientswhichmayresultin
hypoglycemiaduringthenight[5].Also,althoughitlastsfor24hoursinsomepatients,somepatientsrequiretwodaily
injections(figure2).

http://www.uptodate.com.scihub.bz/contents/casesillustratingproblemswithinsulintherapyfordiabetesmellitus?source=search_result&search= 7/7