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How to Best Add or Adjust Medications

Jan 10, 2017

Man, 51 years of age, type 1 diabetes for 32 years. Patient also has history of Class II obesity, CVA, MI and insulin resistance. Patient referred to Obesity Center for weight loss. A1c was 8.2%. Plan was to start Symlin. Symlin was added at 30mcg daily before dinner.  I recommended he get a CGM. He did.

He started losing weight and glucose levels were improving. In time, his dinner preprandial insulin was lowered, and his Symlin was increased to 60mcg. He then did not come into the office for about 6 months. He continued to lose weight. He made an appointment. His weight was up 10 pounds. He told me he had had a severe low blood sugar one night, so stopped the Symlin. We discussed that as he was losing weight, it was most likely he most likely needed to decrease his insulin and or his Symlin at that time.

During this visit, we discussed resuming his Symlin at 30mcg, but he should not start until I see his CGM report from the past 2 weeks. He sent me his report. His glucose levels were actually within target before and after dinner and throughout the night. I contacted him and recommended he decrease his pre and post insulin and basal during the night and start Symlin at 15mcg. We’d go slow. He has done so, done well, including losing weight. Disaster of hypoglycemia averted.

Lessons Learned:

  • When adding Symlin, know glucose numbers. If glucose levels are within target, decrease insulin and start Symlin at a low dose, increasing slowly while decreasing insulin.
  • Never promise patients with type 1 diabetes they will stop insulin. People with type 1 diabetes need to take insulin!
  • Diabetes management is all about balance. Know the type of diabetes you are dealing with and the many effects of medications you are adding to a regimen that best helps the patient manage diabetes.
  • Use CGM to help guide the treatment.


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