Disasters Averted

In assessing an in-patient's diabetic educational needs, I was reviewing with him his in-home regimen for his insulin therapy. Per his report, he stated that he took Levemir 50 units twice a day. I asked if it was by needle, syringe and vial preparation, which it was. I instructed him re: the shelf life of Levemir of 42 days once opened. He stated, "I throw it out after a month, but there is always insulin in the vial.” He also said he has more than an adequate supply. He was receiving his insulin by mail-order, receiving as he should, but not using it in a timely fashion. In other words, he was stockpiling his insulin.

Female, 41 years of age, A1C 7%, Indian, family history of type 2 diabetes, at least one was insulin-requiring. For unknown reasons, perhaps the fact the patient was a personal trainer and “should have known what to do,” her hcp didn’t put much attention on her A1C, nor was she asked to return for follow up. For various reasons, one of which was not having insurance, she did not return to a hcp for 3 years.

Female, 28 years of age, diagnosed with type 1 diabetes at age 25. She was taught to manage her diabetes with a basal/bolus insulin regimen and meal plan prescribed by health care team. She was taught she could eat anything she wanted as long as she covered her carbs with rapid-acting insulin. Her glucose was in control, but she gained 50 pounds over the first year. She then attributed her weight gain to taking insulin, so she would not take enough insulin to cover her glucose levels.

Male, 72 years of age, type 2, insulin requiring diabetes, also taking SGLT-2. Annual physical. No urinary complaints during the visit. Received annual lab work end of work day, glucose elevated much higher than he reports. WBC elevated, 1200, no urine culture, but U/A did show cloudy, leukocyte esterase 2+, wbc >60 H, bacteria many (>50) H, RBC 3-10, H.

Man, 52 years of age, type 2 diabetes, obesity class II on Victoza. He was very pleased with treatment response, lowering glucose levels, feeling full and more satisfied, but having a skin reaction.

Male, 72 years of age, type 2 diabetes, overweight secondary to binge eating disorder. Taking glipizide 20mg daily and metformin 1,000mg twice daily. Hypoglycemic unawareness. Not regularly checking glucose. Recent A1C 6.8%.

In a follow-up visit for an insulin-requiring patient with type 2 DM, it was obvious that the management of his DM had deteriorated. According to his girlfriend, this patient ate only 1-2 meals a day, but they tended to be high-carbohydrate meals. We reviewed the patient's insulin regimem in detail and ascertained that he was using the sliding scale correctly.

I asked a patient with erratic glucose levels where he usually gave his insulin injections to which he responded, "In my arms." I asked, "Could you show me where?" The patient promptly rolled up his sleeves and pointed to the vein in his antecubital space.

Recently a patient presented to our outpatient diabetes education center. His A1C had historically been elevated, despite the initiation of insulin therapy and increasing doses. The patient reported that he had taken all insulin doses as ordered, but was frustrated with his lack of progress.

Female, 58 years of age. On a daily GLP-1 agonist, SGLT-2, metformin, not reaching goal. Started long-acting insulin, using insulin pen. Some improvements, but post prandials still elevated.