Case Studies in Diabetic Care

Jeffrey E. Keller MD

Type 1 DM Case

• 25 year old male, Type 1 diabetic• Heroin addict, shootin’ and dealin’• No doctor, doesn’t check blood sugars• Use regular insulin according to how he feels• Weight 70 kg

Insulin Types

• Basal Insulin– Covers basal metabolic needs– Lantus (glargine) and Levemir (detemir)

• Short-acting insulin– Covers food intake– Humalog (insulin lispro), Novolog (insulin aspart)

Insulin Rule #1

• Basic unit of insulin dosing is Total Daily dose (TDD)

• TDD for most patients is 0.5-1.0 units/Kg• Patient one will start with TDD of 35units/day

Rule #2

• Half TDD should be Lantus, half Humalog• Patient one will take 18 units Lantus/day and

18 units of Humalog

Rule #3

• Humalog covers what the patient eats, should be split among the 3 meals

• Easiest if your diabetic diet consists of the same number of cabs with each meal

• Patient 1: 6 units of humalog each meal

Diabetic snack?

• You have to cover it with Humalog if you do• You have to divide the appropriate number of

daily calories into four parts instead of 3 if you do

• Easiest to NOT have diabetic snacks.

Rule #4

• 500/TDD = carbs covered by each unit of insulin

• Patient # 1 = 14 Carbs/unit

Rule # 5

• 1800/TDD = Blood sugar drop with each unit of Humalog

• Patient 1: 1800/36 = 50

Problems with Sliding Scales

• Reactive, rather than Proactive• Encourages big fluctuations• If used, must be frequently assessed. Why is it

needed? Basal insulin dose wrong? Dietary snacking?

Rule #5 Sliding Scale

• Patient 1– For blood sugars > 400, give 5 extra units of

Humalog– If used, nurse creates task for provider to review

use the next day

Rule # 6 Part A

• Increase insulin by 5-10% every 2-3 days.• Patient 1: TDD 36– Increase 4 units, new TDD 40 units– New Lantus dose 20units/day– New Humalog dose: 7 units/meal

Rule #6 part B

• Add up all of the extra Sliding Scale Units used to recalculate new TDD

• Patient 1:– Used an average of 18 extra units/ day– New TDD: 36 + 18 =54– New Lantus dose: 27units/day– New Humalog dose: 9 units/meal

Rule # 6

• Note that using sliding scale is a MUCH more aggressive change in insulin.

• Be careful!• Consider Rule #7!

Rule # 7

• If a diabetic patient’s blood sugars are consistently high or erratic,

• Check Commissary purchases!

Rule # 8

• 20% of patients should have their Lantus dosed BID

• Levemir does not tend to have this problem as much

Other Considerations

• NPH/Regular insulin 2/3-1/3 Rule• 2/3 Regular-1/3 NPH (Premixed)• 2/3 of TDD given in the AM– Regular covers Breakfast, NPH covers lunch

• 1/3 of TDD given in the PM– Regular covers Dinner, NPH covers basal night

time.• “Sloppy.” Inferior to Lantus/Humalog system.

Other Considerations

• “Compliance Trap” • Patients will often need less insulin in jail

because they will be more compliant with their diet.

Type 2 DM Case

• 48 year old patient with Type 2 diabetes.• Weighs 390 pounds.• Doesn’t take medication: “I control it with

diet.”• Initial blood sugar 450• HbA1C 13.8• Blood Pressure 186/105

Essential EvidenceType 2 DM Summary

• Intensive blood pressure control and lipid lowering, along with smoking cessation, reduce complications and mortality in patients with type 2 diabetes and should be the primary treatment goals. A

• Tight glucose control (hemoglobin A1c < 7.0) reduces microvascular complications of questionable clinical significance, but does not improve quality of life or reduce all-cause mortality. A

• Metformin lowers all-cause mortality independent of glycemic control; similar mortality benefits have not yet been demonstrated for insulin or the other hypoglycemic agents. A

• In type 2 diabetes, self glucose monitoring does not improve hemoglobin A1c levels or reduce complications, but does result in more symptomatic hypoglycemic events. A

• THE ACCORD TRIAL AND CONTROL OF BLOOD GLUCOSE LEVEL IN TYPE 2 DIABETES MELLITUS: TIME TO CHALLENGE CONVENTIONAL WISDOM

• Havas, S., Arch Intern Med 169(2):150, January 26, 2009

Summary

• Type 2 Diabetes is managed very differently than Type 1 Diabetes.

• The only drug shown to reduce long term Death/MI/stroke is Metformin

• Overly aggressive management causes more harm than good

• It is more important to lower blood pressure than to lower blood sugar

Summary

• Type 2 diabetes may have more in common with Celiac Disease than with Type 1 diabetes.

• Disorder of carbohydrate metabolism.• The key to controlling blood sugar in Type 2

DM is DIET.• We can influence diet much more in

correctional setting than outside physicians.

Patient 3 Treatment

• Blood Pressure Meds• Metformin• Dietary counseling/Weight loss• Dietary observation• Oral hypoglycemics?• Insulin?

Diet• Nutritional considerations in type 2 diabetes mellitus• Authors

Linda M Delahanty, MS, RDDavid K McCulloch, MD

• Section Editors Rury R Holman, FRCPTimothy O Lipman, MD

• Deputy Editor Jean E Mulder, MD

• • Last literature review version 17.2: May 2009 | This topic last updated: February 5, 2009• Diet is the most important behavioral aspect of diabetes treatment. Basic principles of nutritional

management, however, are often poorly understood, both by both clinicians and their patients.• Patients commonly fail to adhere to recommendations for diet and exercise, a source of ongoing

frustration for clinicians in caring for their patients with diabetes. One study, as an example, found that fewer than 40 percent of patients with diabetes ate within 20 percent of their prescribed diet [1]. Noncompliance rates among patients with diabetes in another study were 62 percent for diet and 85 percent for exercise [2].

• Dietary compliance is a major factor in achieving glycemic control in type 2 diabetes.

Type 2 Diabetic Snacks

• Diabetic Snack adds calories and carbs• Bad Idea!

When to use additional agents

• Oral Hypoglycemics• Insulin: Lantus• Insulin: Humalog• Additional agents

ADA Consensus • Stepwise Approach to Selecting Treatments for Type 2 Diabetes (American Diabetes Association Consensus Statement)• Diagnosis of type 2 diabetes1,a

↓ Counsel patients regarding lifestyle modification (weight loss, exercise) (expected decrease in A1C 1-2%) [well-validated*] and Initiate metformin [Glucophage, others] 500 mg once or twice daily, titrate to 850 mg to 1000 mg twice daily (expected decrease in A1C 1-2%) [well-validated*] ↓ (A1C 7% or greater three months later) Add sulfonylurea, not glyburide or chlorpropamide (expected decrease in A1C 1-2%) [well validated*] or Add basal insulin (bedtime intermediate-acting insulin or bedtime or morning long-acting insulin) (expected decrease in A1C 1.5%) [well-validated*] or Add pioglitazone [Actos], NOT rosiglitazone [Avandia] (expected decrease in A1C 0.5-1.4%) [less well-validated] or Add exenatide [Byetta] (expected decrease in A1C 0.5-1%) [Insufficient clinical use to be confident regarding safety, less-well-validated] ↓ (A1C 7% or greater three months later) In those receiving metformin and basal insulin or sulfonylurea, change to metformin plus intensive or basal insulin, respectively [well-validated*] or In those receiving metformin plus pioglitazone, add sulfonylurea or change to metformin plus basal insulin [less well-validated] or In those receiving metformin plus exenatide, change to metformin plus pioglitazone and sulfonylurea or metformin plus basal insulin [less well-validated] ↓ (A1C 7% or greater three months later) In patients not yet receiving metformin plus insulin, change to metformin plus basal insulin [well-validated*] or In those receiving metformin plus basal insulin, intensify insulin and continue to adjust [well-validated*]

Patient “DM”(Diabetic Manipulation)

• 30 Y.O. Female, Type 1 DM• Narcotic addiction• Takes Lantus 21 units AM and 13 units PM• Novolog 1 unit for 15 Carbs

Patient “DM” Further History

• Chronic abdominal pain syndrome• Has seen many specialists, many work ups. • No diagnosis• Narcotic addiction. In jail for forging narcotic

prescriptions.

Patient “DM”

• Sugars running high• DKA episode—to ER

Patient “DM”

• “My Provider told me that when I am in pain, my sugars get out of control.”

• C/O abdominal pain and vomiting. “Can’t Eat.”

• Labs normal• HSU. Narcotics. Sugars improve.

Patient “DM”

• Narcotics DC’d• Sugars become high again • “I’d get better if you would treat my pain.”

Patient “DM”

• Rule Number #7• Huge Commissary Purchases!• D/C Commissary Access

Patient “DM”

• Sugars do not improve• “My sugars will get better if you treat my

pain.”

Patient “DM”

• Sent to ER with out-of-control abdominal pain and blood sugars

While at the ER . . .

Patient “DM”

• Returns from ER with controlled BS• Blood sugars uncontrolled next two days• Vomiting, c/o pain• “My sugars will improve if you give me

narcotics.”

Patient “DM”

• Ordered Nurses to administer insulin.

Patient “DM”

• Blood sugars controlled• Patient remains in reasonable diabetic control

for the remainder of her jail stay (2 months)

Other Diabetic Manipulation Tactics

• Get Humalog and then refuse to eat• Eat, get Humalog, then force oneself to vomit.• Dip finger tip in sugar to cause artificially high

reading• Pay other inmates for their commissary items• Eat other inmates leftovers• Lie about doses to naïve staff

Questions/Comments