This article is more than 5 years old. Information may no longer be current.
When the ‘fudge factor’ causes hypoglycemia
Patient education is the most important component of treatment for type 1 diabetes.
Click Here to Manage Email Alerts
 Ronald Tamler |
A 22-year-old man came to see me for management of type 1 diabetes, which was diagnosed 15 years ago. He was complaining of weight gain, erratic blood glucose levels and frequent hypoglycemic episodes. He had impaired hypoglycemic awareness and noted low blood glucose levels approximately 10 times a month, which usually occurred in the middle of the day. The patient preempted them by eating a banana in the late morning. Review of glucose values revealed that the patient measured blood sugar one to three times a day. Glucose levels were anywhere between 34 mg/dL and the 400s. So far, he had not required the help of another person during a hypoglycemic episode.
Other medical history remarkable was one hospitalization for diabetic ketoacidosis many years ago and dyslipidemia. The patient denied any history of diabetic complications. He had just moved to town after finishing college, was very busy with his new job and lived alone. His diet consisted mainly of fast food.
The patient was taking atorvastatin and using lispro (Humalog, Lilly) in an insulin pump, which he had been using for five years. Basal rates varied between 2.85 and 3 U per hour, and the patient was applying a “fudge factor” for his meals and corrections.
Physical exam was remarkable for a young white male in no distress, 5’11,” 256 lb (BMI 36), large neck circumference and obesity. His heart rate was 80, BP 140/80 mmHg. His blood glucose level on finger stick was 28 mg/dL. HbA1c in the office was 7.3% and last LDL measurement was 96 mg/dL.
The patient was mostly concerned about his weight gain and was inquiring about exenatide (Byetta, Amlyn), because he heard that it can induce weight loss.
After giving the patient some dextrose and making a note to recheck his BP when he would be normoglycemic, what is the best next step?
- Go with the patient’s request and prescribe exenatide, 5 mcg sq twice a day.
- Prescribe pramlintide (Symlin, Amlyn), 15 mcg sq with meals.
- Decrease basal rate to 2.7 u/h. Ask the patient to measure his blood glucose levels at least four times a day and keep a diet log. Refer the patient to a diabetes educator.
- Change the patient to a subcutaneous insulin injection regimen.
- Increase basal rate to 3.3 u/h, since blood glucose levels are not at goal.
CASE DISCUSSION
This patient poses a particular challenge, because, in addition to having type 1 diabetes, he also has significant insulin resistance related to his obesity. In essence, he has the worst of both worlds, type 1 diabetes and type 2 diabetes.
Although the patient is right to be worried about his obesity, it is inherently connected to his hypoglycemic events: He increases his food intake at times when he feels hungry, but in addition, he eats preemptively to avoid hypoglycemia. This is something we frequently see in patients who “fudge” their carbohydrate-counting and increase their basal rates over time. Eventually, they become hypoglycemic in times when they are fasting, and the “hunger cycle” leads to erratic glucose levels and weight gain, with remarkably good HbA1c levels.
In this case, backing off on the basal rate allowed the patient to regain hypoglycemia awareness. More importantly, he saw our diabetes educator. A multiple-choice test revealed that this seasoned patient misidentified 32% of foods that contained significant amounts of carbohydrates. Better carb-counting along with sound advice on nutrition and lifestyle allowed him to decrease his basal rates and have less variability in his blood glucose levels. The result was a 6-lb weight loss over the following two months.
Increasing the basal rate (option E) would have exacerbated the problem, and switching back to injection therapy (D) would not have affected the underlying misconception. Exenatide (option A) is a GLP-1 analog that can lead to weight loss in patients with type 2 diabetes. It improves glycemia by stimulating beta-cells to produce more insulin. This is certainly not an option for a patient with a 15-year history of type 1 diabetes.
Finally, pramlintide (option B) is an analog of Amylin, a substance co-secreted along with insulin in healthy humans. Improved postprandial blood glucose levels, increases satiety and can also lead to weight loss. However, since it suppresses postprandial glucagon production, it is not a good agent for patients with frequent hypoglycemic events and poor hypoglycemia awareness.
This case illustrates that, no matter how great technological advances might be, patient education is the most important component of treatment in type 1 diabetes. Fudge does not go well with diabetes.
Ronald Tamler, MD, PhD, MBA, is an Assistant Professor in the Division of Endocrinology at Mount Sinai School of Medicine, NY.