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Taking the jitters out of hypoglycemia
This condition in patients with type 1 diabetes is not always straightforward.
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A 32-year-old woman with type 1 diabetes diagnosed at the age of 3 years presents to the clinic for a follow-up visit. She was started on an insulin pump 2 years ago; her follow-up since then has been inconsistent.
She presented with complaints of frequent hypoglycemic episodes after ratcheting up her insulin regimen 2 weeks before this visit and now returns with a food diary (see Table). She has good hypoglycemia awareness and is undergoing a workup for tachycardia and iron-deficiency anemia.
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Medical history includes diabetic retinopathy, anemia, seizures, cesarean section and tubal ligation. The patient has a 2-year-old daughter. She does not smoke or drink. Medications include insulin aspart administered by insulin infusion pump (see Sidebar), topiramate and ferrous sulfate.
On physical exam, the patient is a lean, afebrile woman, is 62” tall and weighs 125 lb. Blood pressure is 80 mm Hg/50 mm Hg and heart rate is 104 beats per minute. Physical exam is otherwise unremarkable. Pertinent labs include HbA1c, 8.9%; hematocrit, 23%; and finger-stick glucose, 99 mg/dL.
What is the next best step to manage this patient’s blood glucose levels and reduce instances of hypoglycemia?
A. Reduce basal rates by 30% across the board.
B. Reduce daytime insulin-to-carbohydrate bolus ratio to 1 U:16 g.
C. Bring in a can of her favorite soda.
D. Increase target blood glucose to 160 mg/dL.
CASE DISCUSSION:
Answer: C
In general, hypoglycemia warrants diaries for blood glucose, insulin administration and diet to facilitate pattern recognition. Generally, overnight and fasting hypoglycemia will benefit from reduction of basal insulin infusion rate (A). Hypoglycemia after meals stems from the wrong insulin-to-carbohydrate ratio or, more commonly, from wrong carbohydrate estimation by the patient (B). Indeed, this patient was treating hypoglycemia with and accounting for carbohydrates in her preferred soda (C) — a diet cola that boasts less than 1 kcal per can, and no carbohydrates.
Ronald Tamler, MD, PhD, MBA, is clinical director of the Mount Sinai Diabetes Center, N.Y. He is also an Endocrine Today Editorial Board member.