Hemegroup Posted April 29, 2011 Share Posted April 29, 2011 Anyone ever seen such a thing? Had a pt this morning who has been to the ER 4 times this week for serious hypoglycemic episodes (46, the last time). On Lantus at night and Novolin R before meals ... says he drops hard after the Lantus, which I obviously cut out. He said he hasn't taken his insulin in days, he threw it all away after the last visit to the ER. And his random today was 240, with his A1C at 7.7. So ... I left him on the Novolin per heavy sliding scale, and started him on some Metformin. Am I crazy? He's been on insulin for 14 years, started at age 21. Link to comment Share on other sites More sharing options...
bradtPA Posted April 29, 2011 Share Posted April 29, 2011 If you have the ability to run it in your clinic, run a c-peptide. If the c-peptide is low, he is type I, normal to high he is type II. You can base treatment on the outcome. Some of these type ones may do well on 70/30 mix as the only insulin if you are going hypo on lantus and a short acting. My typical type I formula for insulin is to start at 0.5 units per kilogram for the total dose. Split it into half for the basal insulin, then divide the other half into meal boluses on the sliding scale. Hope that is helpful. Link to comment Share on other sites More sharing options...
marilynpac Posted April 30, 2011 Share Posted April 30, 2011 My first thought is that if this man's A1C is 7.7 with a random of 240, he's probably a type 1, adult onset. My Chiro b/c a type 1 at age 45. He said he woke up one day and his pancreas had shut off...why did you put him on Metformin with a A1C of 7.7???? Link to comment Share on other sites More sharing options...
Moderator ventana Posted April 30, 2011 Moderator Share Posted April 30, 2011 have had a few patients do this..... Always attributed it to weight loss, increasing insulin sensitivity, and getting them under control to get rid of glucose toxicity. Most interesting case was a guy who was healthly but got pancreatitis due to a pancreatic head tumour. 1 week initial hospital stay d/c o n orals and insulin. Possible resectable so they had hime do a a whole bunch of imagine and he had a lot of hope for the next 4-5 months. over that same time he had persistent episodes of hypoglycemia and we kept lowering his insulin (I had explained to him that this might be the case - just had a hunch....) to the point where he was off insulin. Now rather he was actually a diabetic or just had his pancrease shut down due to obstruction I would leave up to someone smarter then me... (he was 60ish, heavy set, non smoker, inactive, and AIC was elevated in the hosptial the first time (but I don't remember what it was as this was about 5 years ago) end of story - ended up no being resectable, guy worked at the local VA and had a great boss, he was working up till 2 weeks before he went on hospice and declined very quickly and died.... one of the best/worst cases I have ever had - to see the patient have hope with surgical cure, then have this taken away and he merely crumpled but some of this was an acceptance that he did not want to prolong the inevitable.... Sorry way off track there... anyways, I am quick to add insulin (unless a commercial truck driver - insulin is an AUTOMATIC disqualifiying medicine) to get them under control (glucose toxicity) and then taper way back. Also think it helps the patient realize the severity of their disease and then motivate them to loose weight and exercise..... Link to comment Share on other sites More sharing options...
d2305 Posted April 30, 2011 Share Posted April 30, 2011 If he is type I he will present with dka. If he is obese, he is type II (I know there are exceptions). It is almost impossible for a Pt to loose weight on insulin (type II). If he has insurance, and obese, start Victoza. Link to comment Share on other sites More sharing options...
cecilia Posted April 30, 2011 Share Posted April 30, 2011 Is he a marijuana user? Link to comment Share on other sites More sharing options...
marilynpac Posted April 30, 2011 Share Posted April 30, 2011 Is he a marijuana user? Oh so true....I never thought of that...munchies... Link to comment Share on other sites More sharing options...
marilynpac Posted April 30, 2011 Share Posted April 30, 2011 If he is type I he will present with dka. If he is obese, he is type II (I know there are exceptions). It is almost impossible for a Pt to loose weight on insulin (type II). If he has insurance, and obese, start Victoza. We were told in our Biochem that type 1 can also b/c type II...any thoughts???? Link to comment Share on other sites More sharing options...
d2305 Posted May 1, 2011 Share Posted May 1, 2011 I have to ask an endocrinologist friend about that one. I wound think it's vice versa. Link to comment Share on other sites More sharing options...
marilynpac Posted May 1, 2011 Share Posted May 1, 2011 I have to ask an endocrinologist friend about that one. I wound think it's vice versa. I'll be going to see my endo shortly...I'll ask him too. Link to comment Share on other sites More sharing options...
Hemegroup Posted May 1, 2011 Author Share Posted May 1, 2011 Marilyn, 7.7 is high but not outrageous ... anyhow, Metformin increases insulin sensitivity so it didn't seem illogical since I was cutting out the Lantus. I don't understand your "????" http://www.springerlink.com/content/p64h253758n88656/ http://www.ncbi.nlm.nih.gov/pubmed/17199734 http://care.diabetesjournals.org/content/26/5/1655.2.full I think I'll leave him on the Metformin, and then go with Brad's advice about BID 70/30. The guy is thin ... I'll ask him about his munchie history. Link to comment Share on other sites More sharing options...
marilynpac Posted May 1, 2011 Share Posted May 1, 2011 I know what Metformin does Heme...but a 7.7 isn't high at all. If fact getting a type II DOWN to 7.7 is incredible. They usually hang up by 9.0-11, I've seen even 14. You know the type IIs that pretend they don't have type II. The guy is thin....yes ask him about his munchie hx. Link to comment Share on other sites More sharing options...
bradtPA Posted May 2, 2011 Share Posted May 2, 2011 Thin build, he is type I, although the c peptide will confirm it for you if in doubt. Metformin really won't have much of an because of the lack of beta cell function in a type I diabetic and can increase the chance for hypoglycemia and lactic acidosis. http://care.diabetesjournals.org/content/26/5/1655.1.full Diabetes is tough to treat, but you get a feel for it with practice. And in southeastern NC with it's high Lumbee Indian population type II is epidemic. It definitely keeps me in job security.... With the A1c of 7.7% and hypoglycemia, it sounds like he has been overdosed on his basal insulin, and under dosed on his post prandials. A bit of tweaking, and this is the type patient that you can get to under 6.5%. Link to comment Share on other sites More sharing options...
d2305 Posted May 2, 2011 Share Posted May 2, 2011 Type Is have to count cabs and adjust their Humalog based on how many grams are consumed. Link to comment Share on other sites More sharing options...
Hemegroup Posted May 2, 2011 Author Share Posted May 2, 2011 Thin build, he is type I, although the c peptide will confirm it for you if in doubt. Metformin really won't have much of an because of the lack of beta cell function in a type I diabetic and can increase the chance for hypoglycemia and lactic acidosis. http://care.diabetesjournals.org/content/26/5/1655.1.full Diabetes is tough to treat, but you get a feel for it with practice. And in southeastern NC with it's high Lumbee Indian population type II is epidemic. It definitely keeps me in job security.... With the A1c of 7.7% and hypoglycemia, it sounds like he has been overdosed on his basal insulin, and under dosed on his post prandials. A bit of tweaking, and this is the type patient that you can get to under 6.5%. Hmmm, he's not at any risk for ketoacidosis anytime soon, by my thinking, and it sounds like it's less helpful in Type I's who have a high BMI. That is a good article tho. Anyhow, I'm determined to help him best I can. I will definitely be tweaking him here and there ... you mean pre-prandial, right? I've heard a couple of people saying that short-acting is to be given after meals, but what I read states it's to be given before (30-60 minutes, according to Epocrates, 30 according to our County pharmacist). Link to comment Share on other sites More sharing options...
Hemegroup Posted May 2, 2011 Author Share Posted May 2, 2011 I know what Metformin does Heme...but a 7.7 isn't high at all. If fact getting a type II DOWN to 7.7 is incredible. They usually hang up by 9.0-11, I've seen even 14. You know the type IIs that pretend they don't have type II. The guy is thin....yes ask him about his munchie hx. Yup, that's what I was saying too, that 7.7 isn't terrible for someone like my patient ... I saw a 14.3 the other day, and couldn't counsel my patient strongly enough. He seriously just didn't seem to care (hadn't had a visit in a year, hadn't picked up his insulin in months). But with my OP patient, my hope was that the Metformin would help balance my taking him off his Lantus. I really can't wait to see him in the upcoming week. Link to comment Share on other sites More sharing options...
sbellin Posted May 2, 2011 Share Posted May 2, 2011 We were told in our Biochem that type 1 can also b/c type II...any thoughts???? Type 1 can develop insulin resistance and essnetially have Type 2 then also. Type 1 are generally insulin sensitve and a few units goes a long way, if insulin requirements are climbing then resistance is developing. Link to comment Share on other sites More sharing options...
bradtPA Posted May 2, 2011 Share Posted May 2, 2011 ... you mean pre-prandial, right? I've heard a couple of people saying that short-acting is to be given after meals, but what I read states it's to be given before (30-60 minutes, according to Epocrates, 30 according to our County pharmacist). Actually, I am referring to the post-prandial glucose highs, which you control with short acting insulin in type Is and GLP-1 inhibitors in type Iis. You are right on the insulin, although Apidra can actually be given both before and after. Link to comment Share on other sites More sharing options...
Acebecker Posted October 15, 2011 Share Posted October 15, 2011 A couple of thoughts - first, in determining type I vs II we can, of course, make assumptions based on body habitus. But there are always exceptions. C-peptide can be helpful, but it is not definitive. Anti-GAD antibodies, anti-insulin antibodies and anti-beta cell antibodies (I think those are the 3) are the gold standard. If these are not present in the blood work, then the pt is type II. Remember, even in type II the c-peptide can be low simply because of glucose toxicity. The other thing regarding Metformin is that it's main action is to decrease gluconeogenesis in the liver. It will increase tissue sensitivity peripherally as a secondary (and minor) action. If you want a tissue sensitizor, rosiglitazone is the med for you. I know - potentially terrible SEs. But in a young and otherwise healthy person the risk is low. Start low, go slow, frequent f/u with monitoring and you'll be ok. Regarding hypoglycemia on insulin - the timing of the lows is what you need to be worried about. AM lows means that the Lantus is the culprit - consider splitting to bid if the dose is low enough that you suspect that the bolus is the problem. Sliding scales - use caution. Most sliding scales don't account for CHO intake at the meal, so you're always chasing a high and end up causing more lows. I feel that unless the pt will count CHO and take only the Novolog they need to cover those CHO then the sliding scale is less than ideal. I will use it for many patients who can't manage to count the CHO though. DM is a tough nut to crack. Especially with a noncompliant population. Andrew Link to comment Share on other sites More sharing options...
HopefulPA Posted October 15, 2011 Share Posted October 15, 2011 The only time I have use short acting tidpc is with my dementia pts where eating is an issue. Instructing the caregivers to administer either low or mod sliding scale based on amount of meal eaten and it seems to be working thus far with the hypo events. Link to comment Share on other sites More sharing options...
HopefulPA Posted October 15, 2011 Share Posted October 15, 2011 The only time I have use short acting tidpc is with my dementia pts where eating is an issue. Instructing the caregivers to administer either low or mod sliding scale based on amount of meal eaten and it seems to be working thus far with the hypo events. Link to comment Share on other sites More sharing options...
LIPPER Posted October 15, 2011 Share Posted October 15, 2011 Wt loss, inconsistent PO intake and gastroparesis... I like Janumet. Would it be unheard of for a IDDM pt to develop an uderlying Insulinoma? Link to comment Share on other sites More sharing options...
LIPPER Posted October 15, 2011 Share Posted October 15, 2011 Wt loss, inconsistent PO intake and gastroparesis... I like Janumet. Would it be unheard of for a IDDM pt to develop an uderlying Insulinoma? Link to comment Share on other sites More sharing options...
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