November 6, 2018 : DCMS #422

DISASTERS AVERTED — Near Miss Case Studies

When Family Members Are HCPs

EXCLUSIVE INTERVIEW — Candid Video Interviews with Top Practitioners

Linda Parks on Glooko and Digital Therapeutics

HOMERUN SLIDES — Great Clinical Presentation Highlights

CGM Review of Clinical Outcomes Studies Part 2

CLINICAL GEMS — The Best from Diabetes Texts

International Textbook of Diabetes Mellitus, 4th Ed., Excerpt #150: Glucose Toxicity Part 6

MOST POPULAR ARTICLES OF THE MONTH

#1 What Not to Trust
#2 WHO Guidelines Recommend Treatment Intensifications in Type 2 Diabetes
#3 Delaying the Progression of Type 1 Diabetes

Last week I spent a couple of hours with a group of Internal Medicine residents at a local hospital. The Director of Residents had called me in to talk about the actions of insulin and how to dose properly.

My first question to the group was about Humalog 75/25. It was a simple question…. Which is the long acting and which is the short acting? 60% of the residents got it backwards stating that the 75% represented the short-acting component. When I asked them why this was important and what their mistake could have caused, most had no real idea.

The next question dealt with calculating a rapid-acting dose to add to basal insulin. The general consensus was to add 5-6 units before each meal and only 20% of the participants mentioned that the patients should increase their monitoring.

We spent the rest of the meeting going over how to dose insulin and which insulin to use at what time. This pointed out that many times we as medical professionals think we are experts at everything health-related.

To see how this can really be bad for our patients’ health, check out this week’s Disaster Averted, which covers what happens when a family member thinks they are an insulin expert.

Dave Joffe

Editor-in-chief

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.

Linda Parks, Certified Diabetes Educator, has worked in diabetes care for over 25 years, both as a clinician and in the diabetes technology industry. Her passion is in bringing new technologies to market that make a difference in the lives of people living with diabetes and their loved ones.  She believes it is not just the technology, but the data from the devices translated into actionable insights that bring significant changes. Linda has held positions at Abbott Diabetes Care, Tandem and Senseonics and is currently the Director, Clinical Development & Research at Glooko, Inc.  She is a Certified Diabetes Educator and holds a MS in Nursing Science and Healthcare Leadership from the Betty Irene Moore School of Nursing, University of California, Davis.

In this week’s Homerun Slides, a focus on CGM outcomes.

Clinical significance of glucose toxicity: After diagnosis of type 1 diabetes, initiation of insulin therapy induces partial clinical remission in ∼30% of the patients during the first year. This honeymoon period is characterized by normoglycemia, recovery of endogenous insulin secretion, and by improved insulin sensitivity. Although correction of several alterations secondary to insulin deficiency, such as increased counterregulatory hormone secretion, hyperosmolarity, acidosis, electrolyte changes and high free fatty acids could contribute to normalization of insulin secretion and sensitivity, reversal of glucose toxicity may also be of importance for the occurrence of remission.

I received a call and glucose numbers from patient who has type 2 diabetes, usually with hyperglycemia, never hypoglycemia. I noticed there was at least a 12-hour span since the last glucose reading. His glucose levels after the over-12-hour lag showed hypoglycemia during the  night when the numbers start showing. His glucose averaged 53 during that time, but it has been running 150 and over, and we have been slowly increasing his insulin.

Medications suggested for second- and third-line treatments for diabetes management following treatment failure with metformin and sulfonylureas.

Exercise can lengthen remission after being diagnosed with type 1 diabetes.