Disasters Averted

A teenage type 1 on an insulin pump was seen in our office for follow up. The download on her pump revealed some interesting numbers. First off, her glucose levels were out of target range and secondly her I:CHO ratio and her insulin sensitivity looked more like the numbers of a type 2 diabetic vs a type 1. Her I:CHO was 1:16 and her insulin sensitivity was 1:30. In my experience, I'm used to seeing a lower I:CHO and a higher insulin sensitivity in type 1 vs type 2.

A 15-year-old type 1 diabetic is seen who frequently forgets to take her insulin because of time issues. At the time of her initial appointment, her A1C was 10.4. After discussing issues preventing her from taking her insulin, I suggested that she take her insulin through her clothes.

Some think you can’t be too rich or too thin. A stylish female, type 2 diabetes, 46 years of age came into the office (a weight loss clinic) for a follow up. Everyone was telling her how great she looked. She said she was feeling great and excited because she could fit into clothes she couldn’t fit in the past few years. She lost 9 pounds in three months. She had not been self monitoring her glucose. She was thrilled, but her doctor wasn’t so thrilled, at least not yet. He was concerned her glucose was elevated.

19-year-old female, type 1, insulin pump, and counting carbs, wanted to use a particular food plan that touted no counting and no need to worry about numbers. She asked me what I thought of that and I informed her that for weight loss, this can work for some, but she has type 1 diabetes, and she will need to check her glucose and most likely count carbs, or at least make some adjustments in her boluses at each meal.

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.

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.