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Don’t let hypoglycemia drag your patient down
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A 29-year-old man came to see me for the management of his diabetes. He had been diagnosed with type 1 diabetes at the age of 18 and was complaining of frequent hypoglycemic events without warning.
 Ronald Tamler |
He had absolutely no awareness of hypoglycemia and reported several episodes requiring the help of another party per month. These episodes were sometimes accompanied by seizures. There was no discernable diurnal pattern; the episodes could happen after meals, before meals or during his sleep. The young man had lost his driver’s license and several jobs due to his propensity for sudden hypoglycemia-induced seizures. Because of his concern regarding low blood sugars, he deliberately undertreated himself with glargine 10 U twice a day and a conservative “guestimate” of 1 U lispro for every 20 g carbohydrates, with an indeterminate “fudge factor.” The patient stated that he would correct approximately 70 mg/dL for every U of insulin, but that he was fearful of blood glucose levels <200 mg/dL. He also measured his blood glucose levels four times a day and stated that he would measure it more often if he had more test strips.
Other medical history included hypothyroidism and cleft palate repair in childhood. Medication consisted of glargine and lispro, as well as levothyroxine sodium, Vitamin C and a multivitamin. He had no known allergies, rarely drank alcohol, never smoked and did not use recreational drugs. The patient was working as an illustrator for comic books and had a girlfriend.
Review of glucometer data demonstrated generally elevated blood glucose levels in the 200s and 300s, interspersed with levels around 20 to 30 mg/dL three to four times per week. There was no noticeable pattern of these events. Physical exam was rather unremarkable, with a lean white male with several scars after falls. Sense of vibration and response to monofilament testing were normal. HbA1c was 7.8%, other labs were unremarkable.
Which of the following actions is inappropriate for the management of this patient’s diabetes?
- Ask the patient to keep a food and glucose log and record how much insulin he is giving at what time.
- Prescribe a glucagon kit and make sure that the patient’s girlfriend is trained to use it.
- Prescribe pramlintide, 15 mcg with meals, to be uptitrated as tolerated
- Prescribe 10 test strips per day and petition the patient’s insurance company to carry the cost.
- Start the process of equipping the patient with a sensor that allows continuous glucose monitoring.
CASE DISCUSSION
This young man’s life is severely impaired due to his hypoglycemia unawareness. Often, hypoglycemia awareness will improve once glycemic control is loosened, but that was not the case with this patient.
The first step in the management consists of pure detective work (option A): I asked the patient to record his food intake and insulin doses (one can even prescribe a lispro pen that will record the amounts of insulin given), and our excellent nurse practitioner/diabetes educator went through the patients’ log with him. It turned out that the rare occasions when he imbibed alcoholic beverages induced a delayed hypoglycemic response, but they were not to blame for all the episodes.
Emergencies demand preparedness, and in addition to recommending dextrose gel on the patient at all times, I made sure that the person who spends the most time with him was trained in using a glucagon kit (option B). Insurance companies will often limit the amount of test strips covered for patients with diabetes, and it is our obligation as physicians to make sure that our patients receive the care that is feasible for their condition. In this case, wide fluctuations made frequent testing a necessity (option D). Often however, it is not the insurance companies that limit testing frequency, but rather the patients themselves.
Recently, there have been three companies that have brought technology to the market which allows for continuous glucose monitoring (option E). These are devices that work as sensors in the subcutaneous interstitium for up to a week and wirelessly send updates to a receiver every few minutes. While the price is significant, accuracy is imperfect and many insurance companies are hesitant to carry the cost, this would be an instance when such a sensor could shine, as it could sound an alarm in the case of hypoglycemia or even rapidly dropping blood glucose levels.
Pramlintide (option C) is an injectable analog, a substance co-secreted with insulin by the healthy pancreas. Taken with meals, pramlintide is useful in reducing postprandial hyperglycemia and also has favorable effects on weight. However, it also abrogates glucagon response and makes patients with poor hypoglycemia awareness even more vulnerable to severe hypoglycemia events.
Ronald Tamler, MD, PhD, MBA, is an Assistant Professor in the Division of Endocrinology at Mount Sinai School of Medicine, N.Y.