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Uncontrolled blood sugars? Think of the munchies!
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A 41-year-old white male came to see me for an initial visit. He had been diagnosed with type 1 diabetes at age 11 and was taking glargine 15 units at bedtime as well as aspart with meals, based on a sliding scale.
The patient stated that he had fixed times and contents of meals: 45 g of carbohydrates for breakfast and lunch and 60 g of carbohydrates for dinner. He stated that he was injecting insulin with breakfast, lunch and dinner. However, he was concerned about his erratic blood glucose levels, particularly about highs to the 400s in the mornings. The patient did not keep a glucose log and forgot to bring his glucometer. He stated that he measured his blood sugars at least five times a day.
According to patient recall, his blood glucose levels were ‘fine’ the rest of the day. In addition, the patient was concerned about his weight of 222 lb with a recent gain of 35 lb over the past two years and was inquiring about dietary advice. The patient denied neuropathy and nephropathy, but stated that he did have retinopathy. He had not seen an ophthalmologist in three years. The patient was interested in starting treatment with an insulin pump.
Other medical history consisted of unilateral ectopic kidney since birth, dyslipidemia, multiple trigger finger surgeries as well as coronary artery disease with percutaneous coronary intervention with stent placement two years ago, depression, hypertension, and retinal laser surgery.
 Ronald Tamler |
Medications: Insulin regimen as above, atorvastatin, losartan, escitalopram and aspirin. The patient was an actor (between jobs) and denied nicotine use. He stated that he had one drink per week.
On physical examination, this was an obese 41-year-old white male in no acute distress. He was 5 ft, 6 in tall, BMI 35, heart rate 68, BP 124/70. Exam unremarkable with exception of sense of vibration 4/8 bilaterally. His response to monofilament testing was normal. The patient appeared depressed during the interview. He was given a prescription for fasting labs but never got around to having the lab draw.
What is the key to managing this patient’s hyperglycemia and obesity?
- Change the timing of the glargine dose from bedtime to the morning.
- Send the patient home with an insulin pump and a continuous glucose monitoring device that will track his glucose levels over three days.
- Ask about night-time snacking, compliance with insulin regimen and get a full social history.
- Prescribe pramlintide with meals.
- Refer the patient to bariatric surgery.
CASE DISCUSSION
The answer is C.
This patient has two problems that have the same root: Obesity and elevated morning blood glucose levels. This case also represents the common challenge of a patient with poor follow-up and limited availability of data. Nonetheless, one can make sense of this puzzle. Elevated morning blood glucose levels are often related to the dawn phenomenon, a circadian elevation of blood glucose levels early in the day. Other reasons could be night-time hypoglycemia with subsequent activation of the counter-regulatory axis, and the most banal reason: elevated blood glucose levels the night before.
One underrecognized source of high “fasting” blood glucose levels is night-time snacking, which is extremely common, not just in patients with diabetes. This is often exacerbated by the fact that snacks are not considered “meals,” thus not considered to require an injection with insulin.
In this particular instance, the patient admitted to daily use of marijuana. The active ingredient, tetrahydrocannabinol, not only induces sedentary behavior, but also triggers a strong orexic response. In fact, the THC receptor is currently being targeted by pharmaceutical companies to generate weight-loss drugs. In this case, the patient was smoking marijuana at night, had “the munchies,” snacked on carb-containing foods (usually potato chips) and was too “absent-minded” to use insulin with this meal. Regular consumption of recreational drugs also makes the patient ineligible for bariatric surgery, and the track record of poor follow-up does not help either (E). Pramlintide can lower post-prandial blood glucose levels and induce some weight loss, but it would not be the right choice at this time, since the patient is not even using insulin with his night-time snack (D).
A continuous glucose monitoring sensor certainly adds data and would have shown the night-time glucose spike in this case (B). However, if this intervention is to be successful, patients need to meticulously log their food consumption and insulin injections. It would make sense to have the patient record his blood glucose levels and bring his glucometer first. An insulin pump will not improve matters either, as it does not address the actual problem and poses higher demands on compliance on the patient.
Finally, glargine can on occasion have a duration of action that is shorter than 24 hours. When given in the evening, as is the case here, this would however have the effect of high evening glucose levels. Switching the dose to the morning would not improve this patient’s hyperglycemia before breakfast.
In this case, the patient saw our nurse-practitioner/diabetes educator and was referred to a psychiatrist that specialized in drug addiction.
Ronald Tamler, MD, PhD, MBA, is an Assistant Professor in the Division of Endocrinology at Mount Sinai School of Medicine, NY.