Disasters Averted

A man with type 1 diabetes started an exercise program to help him manage his early morning highs. He exercised every evening, at which time his glucose levels would drop during and after exercise. Thinking that exercise would lower his early morning highs, he did not take his insulin before exercise. He was surprised to see his glucose would go up after exercise rather than go down.

One of my long term patients called my office because she could not figure out what was happening with her post breakfast glucose readings. She counted carbs and would typically have a 2 hour ppg of no more than 145 mg/dl but even though her pre-breakfast readings were around 110 mg/dl she was experiencing glucose levels near 200 mg/dl. I had her do a morning food diary for 7 days and we identified 3 days when she was eating French toast when her readings were going over 200 mg/dl. This meal had never been a problem in the past.

As the incidence of diabetes increases, insulin use can reasonably be expected to increase, and the mistakes will no doubt increase as well. Insulin is a very powerful medication, and some of these mistakes will require the ambulance, the hospital, or worse.

Last week I saw a patient who seemed to be losing control of her blood glucose levels. She had been doing well and her A1c had been around 6.0 - 6.3 for the past couple of years. She was doing this while only on metformin 1000 twice a day. She was referred to me by her physician because of high after-meal readings ranging up to 350 mg/dl. I went over her medical history and medications looking for a possible problem and found nothing.

My colleague and I were working with a client new to insulin. We each saw him separately. He was taking Lantus and Humalog by syringe at meals. He had been taught how to use the syringe by his physician's office staff. He was claiming much different numbers than expected for his mealtime doses.

After starting a new medication (gabapentin) for his neuropathy, a patient of mine gained 30lbs and presented with peripheral edema without symptoms.

I visited a housebound patient who had uncontrolled blood glucose, in spite of her physician having increased her insulin dose over a period of two weeks to twice her previous dose.  The physician requested that I ask in depth about any factors that might be causing her to need so much more insulin.

I recently started working with a 58 y/o gentleman who had insulin dependent type 2 diabetes. He was 110 pounds overweight, and was using 120 units of Lantus and 30 units of Humalog daily. His most recent A1c was 8.6. The program he was placed on involved drinking a medical liquid food supplement 5 times a day which contains 12 grams of carbs per serving plus a meal that consisted of a small amount of protein and vegetables.

A VA Pharmacist received an order for 40 units of U-500 insulin and questioned its validity. The actual dose desired by the physician was 200 units. The physician indicated the 40 units reflected the mark on a U 100 syringe to which the patient was to draw back the plunger.  This was found to be a common practice so the VA developed a system requirement which required physicians to indicate the total units/mls (Example: 200 units/.4ml) for U 500. Insulin must be in the chart and syringes calibrated in mls must be used.

I had the pleasure of working with an elderly gentleman who was living alone. When he switched from insulin pens to a vial and syringe due to his insurance, his numbers started to increase into the 400’s and 500’s. He was feeling weak and lethargic but fortunately was able to pull …