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A touch of sugar
A 42-year-old woman comes to see me for follow-up consultation regarding management of type 1 diabetes. She proudly reports excellent glycemic control since her last visit.
She reports rare hypoglycemia with good awareness and is using an insulin pump with insulin aspart (Novolog, Novo Nordisk). Review of systems is otherwise unremarkable. Other medical history includes acquired hypothyroidism and hypertension. Medications include ramipril, aspirin, levothyroxine and insulin aspart. The patient has sensitivity to theophylline.
She is married, has two children and describes her job as being “Super Mom.” She denies use of nicotine, alcohol or recreational drugs. There is a strong family history with diabetes in her mother and both maternal grandparents.
Physical exam: blood pressure, 124 mm Hg/82 mm Hg; pulse, 96; height, 5’3”; weight, 123 lb. Exam otherwise unremarkable. HbA1c is 6.4%. Blood glucose levels are stable throughout the week, with levels around 100 mg/dL fasting and 90 mg/dL to 180 mg/dL at random. However, the patient has erratic blood glucose levels on Sunday afternoons.
Here is an example:
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7:47 – 103 mg/dL
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11:14 – 142 mg/dL (before brunch)
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13:02 – 162 mg/dL
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14:01 – 347 mg/dL
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14:03 – 121 mg/dL
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14:07 – 124 mg/dL
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14:11 – 426 mg/dL
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14:14 – 113 mg/dL
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Rest of the day: blood sugar in the 80s to low 100s
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What is the next best step in the management of this patient?
A. Devise a “Sunday basal rate” for the patient’s insulin pump regimen, which is 30% higher than during the week.
B. Change the patient’s bolus insulin to carbohydrate ratio to administer a larger bolus for Sunday brunch.
C. Ask the patient what she was doing at the time that had the very high readings that she would not do on other days.
D. Prescribe a new glucometer, since this meter is clearly dysfunctional.
E. Prescribe a new pump, since it has a weekly malfunction.
CASE DISCUSSION:
Answer: C
This patient with type 1 diabetes has an excellent HbA1c at 6.4% that is not consistent with the occasional excursions into the 300s and 400s seen on Sunday afternoons. It is even more remarkable that the numbers were not reproduced when she repeated her blood sugar measurement. With such an erratic pattern, a higher basal rate would just drive the patient into hypoglycemia with subsequent rebound hyperglycemia and roller coaster blood sugars (A). Similarly, a larger bolus with brunch would not affect isolated hyperglycemia three or four hours later, and would carry the risk of hypoglycemia (B).
Erratic blood glucose measurements do often point to dysfunctional equipment (D and E), but with a weekly pattern of this kind it pays to play detective.
This is actually a case where I learned something from my patient. (I learn from my patients all the time, but I like to pretend like I have known these things all along.) “Super Mom” was baking with her two children every Sunday. While baking, she would touch baking products, including … sugar and starches. She noticed that she would have very high blood sugar readings after coming into contact with these baking products without having ingested any. Her blood glucose levels miraculously normalized after meticulous hand-washing. I guess this give a new meaning to saying to a patient, “You have a touch of sugar!”
Ronald Tamler, MD, PhD, MBA, is Assistant Professor in the Division of Endocrinology at Mount Sinai School of Medicine, N.Y.