Interactive diabetes case 6: Uncontrolled diabetes in a 64-year-old woman treated with insulin
- Lloyd Axelrod, MD
Lloyd Axelrod, MD
- Associate Professor of Medicine
- Harvard Medical School
A 64-year-old woman, a retired office worker, has persistently variable glucose values on multiple injections of insulin a day.
Three years ago the patient was admitted to another hospital in diabetic ketoacidosis in the setting of an upper respiratory infection. She was started on insulin then and has been on insulin ever since, currently taking NPH insulin 20 units every morning and using a sliding scale of aspart insulin sporadically. Her blood glucose values are variable when checked twice a day, before breakfast and before dinner. Most fasting blood glucose values are in the 200 to 300 mg/dL (11.1 to 16.7 mmol/L) range, but some are in the 40 to 60 mg/dL (2.2 to 3.3 mmol/L) range. Blood glucose values before supper vary from 44 to 327 mg/dL (2.4 to 18.2 mmol/L), with no apparent pattern. She is having occasional nocturnal insulin reactions. The glycated hemoglobin (A1C) is 10.20 percent. The patient says she counts carbohydrates and avoids concentrated sweets. She is 5' 1" tall, weighs 111 pounds, and has a body mass index (BMI) of 21.
What do you recommend?
●A 1200-calorie diet to reduce variability in the blood glucose levels. (See "Interactive diabetes case 6: Uncontrolled diabetes in a 64-year-old woman treated with insulin - A1".)
●The addition of metformin 500 mg orally twice a day before meals to reduce the peak glucose values. (See "Interactive diabetes case 6: Uncontrolled diabetes in a 64-year-old woman treated with insulin - A2".)