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When the steel is mightier than the pen: Removing obstacles to glycemic control
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A 53-year-old Hispanic woman presents for an initial evaluation of type 2 diabetes. The patient was initially diagnosed with type 2 diabetes 15 years ago. She has since been noticing mild paresthesias of the feet. She reports adherence to her prescribed medical regimen but incomplete adherence to recommended physical activity and dietary regimens.
Past medical history consists of diabetic neuropathy, hypertension, meralgia paresthetica of the left leg, hidradenitis suppurativa, hypertension, obesity and hyperlipidemia. Her surgical history includes carpal tunnel release surgery and tonsillectomy.
The patient did not bring her glucose meter (OneTouch, LifeScan) to the appointment.
Her medications include exenatide 10 mcg/0.04 mL subcutaneously two times per day (Byetta, Amylin); glyburide plus metformin 2.5 mg/500 mg orally two times per day with meals (Glucovance, Bristol-Myers Squibb); rosiglitazone 4 mg orally two times per day (Avandia, GlaxoSmithKline); atorvastatin 40 mg orally daily (Lipitor, Pfizer); olmesartan 20 mg orally daily (Benicar, Daiichi Sankyo); aspirin 81 mg orally daily; carbamazepine 200 mg orally three times per day; and topical lidocaine 5% (700 mg patch).
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The patient quit smoking last year after 15 pack-years and does not drink alcohol or use recreational drugs. She works as a pediatric ICU nurse and is comfortable using medical jargon.
On physical exam, the patient has a blood pressure of 124/80 mm Hg; pulse 92; height 5’3”; weight 187 lb; BMI 33. She is alert and in no distress. Her cardiovascular, respiratory and gastrointestinal exams are unremarkable. Sense of vibration: 4/8 left, 6/8 right internal malleolus, normal response to monofilament testing bilaterally.
There is a callus on the dorsum of the right fifth toe and abrasions on both feet after pedicure with vigorous scraping. Blood glucose on finger stick is 328 mg/dL and point-of-care HbA1c is 10.3%
The patient is taken off rosiglitazone and glyburide plus metformin and started on extended-release metformin 750 mg two times per day and insulin detemir injection 20 units per day (Levemir FlexPen, Novo Nordisk) with 32-gauge pen needles and a titration regimen. She is to continue exenatide.
The next day, the patient calls to ask for a new prescription for insulin detemir. She has been unable to inject more than 2 or 3 units at a time. She had suspected pen malfunction and, therefore, tried a different pen, with the same result. She suspects that she has been given a dysfunctional batch of insulin pens and wants to pick up a different package from a different pharmacy in a different part of town.
What is the best next step in managing this patient?
A. Prescribe a different package of insulin detemir injection pens from a different pharmacy in a different part of town.
B. Prescribe larger-bore pen needles (25-gauge).
C. Invite the patient to come back to the practice and demonstrate how she prepares and executes insulin injections.
D. Prescribe insulin glargine injection pens (Lantus Solostar Pen, Sanofi-Aventis) to facilitate easier injections.
E. Ask the patient to see a psychologist to overcome her resistance to insulin therapy.
CASE DISCUSSION:
Correct answer: C
This is a classic case of “never assume anything.” The patient, despite being an ICU nurse, was unfamiliar with the proper assembly and operation of an insulin pen device. When she demonstrated an injection, she was indeed unable to inject more than 2 or 3 units at a time before the plunger stopped. Upon closer examination, it turned out that she was not twisting the pen needle all the way onto the insulin pen device. Once the needle was fully attached, there was no trouble injecting the full prescribed 20 units at a time.
Ronald Tamler, MD, PhD, MBA, is assistant professor in the division of endocrinology at Mount Sinai School of Medicine, N.Y.
Disclosure: Dr. Tamler reports no relevant financial disclosures.