This Weeks Question
You have a patient who has type
1 diabetes and, despite her excellent readings (in her log book) with
multiple daily injections, her A1c remains very high: 12% to 14%.
She has used an insulin pump, but the results didn't change. What
would you do?
1. Adjust the basal dose of insulin if
the patients fasting BG is elevated
2. Adjust the bolus calculations and dose if postprandial readings
are elevated.
3. Supply a new BG meter
4. Call the patients pharmacy to check the amount of insulin being
purchased.
5. All of the Above
6. 1 and 3
7. 3 and 4
This is a clinical situation that is a bit more
extreme, but similar patients have tended to display 1 of 2 characteristics.
By far the most common is that they are malingering and purposefully
leading you and, often, their families astray. If they bring in a
glucose log, fairly common mistakes by patients include:
I think the best hint from a glucose log would
be if the numbers are never high (over 200 mg/dL) and never low (under
70 mg/dL). Virtually no patients with type 1 diabetes can maintain
their glucose values that stably for more than a few days, and even
that would be quite unusual.
More often than not, malingerers will come up with a wide assortment
of excuses for why they forgot to bring in their logs. These behaviors
can be best demonstrated by providing the patient with a meter with
memory and when the patient returns either scrolling back in the memory
or downloading the meter to determine how often the patient is checking
and what values are present. I have seen patients that have gone to
the extreme of using other people's blood, a pet's blood, or the manufacturer's
control solution to get good glucose values.
Another route of investigation is to really nail them down on how
often they test their blood glucose, how much insulin they take, and
how often they take it by finding out where they purchase their insulin
and supplies and how much they get at one time. By calling the pharmacy,
I have occasionally been able to determine that the patient was not
buying nearly enough insulin or testing strips.
Comments?
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