History of present illness
A patient, Ms. B., was diagnosed with type 1 diabetes three years ago. At the time of diagnosis, Ms. B had positive glutamic acid decarboxylase (GAD) antibodies, her blood sugar level was approximately 1200 mg/dL and her hemoglobin A1c levels were 10.8%. A c-peptide level had been obtained and found to be decreased at 0.2, helping to confirm the diagnosis of type 1 diabetes.
At presentation, Ms. B.’s hemoglobin A1c was >14%. She was prescribed 8 units insulin glargine (Lantus) at bedtime, once daily. The patient reported regularly taking 3 units insulin aspart with meals and adding in an additional 1 unit for every 15 to 20 grams of carbohydrates she consumed above that.
Ms. B. also used a correction dose at meal times and at bedtime starting at 121 to 180 mg/dL adding 1 unit and then adding 1 unit for every 60-point elevation after that.
The patient reported metering four times daily, prior to each meal and at bedtime. Upon review of a downloaded meter at presentation, Ms. B.’s blood sugar levels were elevated. She had 105 values in a one-month time. Her average is 408 mg/dL over the last long.The majority of the patient’s readings were in the 300 to 400 mg/dL range.
Although Ms. B. said she tried to eat 70 grams of carbohydrates with meals, sometimes she ate more than that. The patient admitted to smoking less than one pack of cigarettes per day, she was motivated for smoking cessation. She did not exercise regularly.
Ms. B. reported that she had hypoglycemia episodes in the past, but denied any recent history. She admitted she was fearful of hypoglycemic episodes and had purposely tried to run her blood glucose values higher in an effort to prevent hypoglycemia. The patient had a prescription for glucagon which she has not had to use.
The patient denied nausea or vomiting. She reported recent blurry vision, thirst, and increased urination for the last one month, which she had at the time of initial diagnosis of diabetes. The return of those symptoms motivated Ms. B.’s diabetes follow-up.
Ms. B.’s lower right and left abdomen, the sites of insulin injection, were hardened at presentation.
Review of diabetes symptoms
The patient’s last eye exam was three years prior, no retinopathy was found at that time. Ms. B.’s blood pressure was 100/65; she was not on any blood pressure medications.
Ms. B.’s most recent cholesterol panel, taken in the past year, revealed her total cholesterol was 182; triglycerides 89; HDL 85; LDL 79. She was not on a statin.
The patient noted neuropathy in her left foot and left hand between her second and third digit on the hand.
Within the last year, Ms. B.’s creatinine was 0.6 with an estimated glomerular filtration rate of greater than 60. Her microalbumin level was less than 5, and albumin-creatinine ratio was less than 8. Urinalysis on day of visit and showed no ketones in the urine.
At presentation, the patient’s weighed 55.2 kg with a body mass index of 18. Ms. B. stated that she had lost between six to 10 pounds in the last few months in the setting of elevated blood sugar readings; she had not been working to lose weight, nor did she endorse using less insulin in an effort to lose weight.
Ms. B. stated that she felt more stressed out than usual; her mother was recently diagnosed with a brain tumor.
The patient’s thyroid hormone levels (TSH) was within normal limits at 1.7.
Click the links to answer the following questions regarding the management of this patient:
- What would be appropriate next steps in glucose management?
- What are other autoimmune conditions sometimes associated with type 1 diabetes?
- Why is it important to ask about weight, in a patient with type 1 diabetes, and elevated hemoglobin A1c?