When Family Members Are HCPs

Male, 68 years of age, type 2 diabetes, Italian, on long-acting insulin and GLP-1. Basal glucose levels are within target as are most post-prandials except every night after dinner. We have talked several times about lowering carbs, which he has done during the daytime, but has difficulty cutting back on dinner meal.

We had in the past discussed taking rapid-acting insulin for meals, but he refused. After two weeks, patient sent me his CGM results. Even he started getting concerned about his evening post-prandial levels. Rapid-acting insulin added before dinner and post-prandials are now in target range. He has not once complained about taking the rapid-acting insulin before dinner.

Son, who is an RN, called me one evening and told me he told his father to cut back on his rapid-acting insulin because of the way a basal and rapid-acting insulin can act together. He said, “This could cause hypoglycemia.”

I re-educated the son and patient on the onset, peak and action times of the different insulins and that since the patient is eating and eating high carb dinners as he does, he needs the amount of rapid insulin prescribed. The time before eating may change with his glucose level going into the meal. For example, if his glucose is 80-120, he should take the rapid-acting insulin closer to the time he eats, but if his glucose is higher, he can take the rapid-acting closer to 15 minutes before he eats. How do I know this? By looking at his patterns (often his post-prandial dinner levels were 250-300) and the experience that rapid-acting insulin’s onset of action varies with different patients. For this patient, it is as I had recommended the patient take it, and he has done fine.

The disaster averted has been the post-prandial elevated glucose levels and also not taking away the patient’s quality of life. The patient has tried and tried to cut back on carbs and has done so, but dinner has been extremely tough and he’s felt deprived when he cut back. I remembered his culture and took that into consideration. He has been a lot happier and has much better glucose levels.

Lessons Learned:

• Not all health care providers understand the difference between the types of insulins, how or why they are prescribed, and oftentimes will hold insulin that does not need to be held.
• Often health care providers see a glucose in range and will hold insulin for fear of hypoglycemia when in fact it’s the insulin that is causing or helping to keep the glucose in target range.
• Insulins’ onsets can differ depending on the person. Learn more by studying the particular patient’s glucose patterns using CGM. Recommend from there.
• Always take each individual’s likes, dislikes and culture into consideration when designing meal plans with your patients.

Joy Pape, FNP-CDE
Medical Editor, DiabetesInControl

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