A 51-year-old woman comes to the office due to excessive sweating at night. She has had type 2 diabetes mellitus for the past 10 years and was started on insulin therapy 3 years ago due to suboptimal glycemic control (hemoglobin A1c 11%) on glipizide and metformin; metformin was continued but glipizide was stopped at that time. In addition to metformin, the patient currently takes 34 units of insulin glargine at bedtime and 6 units of insulin lispro before meals 3 times a day. She also eats a bedtime snack daily and has gained about 3.2 kg (7 lb) since insulin therapy was started. The patient has no chronic complications of diabetes mellitus. Medical history is notable for obstructive sleep apnea, hypertension, dyslipidemia, and obesity. She does not work, has a sedentary lifestyle, and does not use tobacco or alcohol.
Blood pressure is 140/90 mm Hg and pulse is 80/min. BMI is 34 kg/m². Jugular venous pressure is not elevated. There is trace pedal edema. The remainder of the physical examination is normal.
Hemoglobin A1c is 6.7%. Fingerstick blood glucose levels (mg/dL) for the 4 days prior to the office visit are as follows:
Which of the following is the most appropriate next step in management of this patient's diabetes mellitus?

Question

A 51-year-old woman comes to the office due to excessive sweating at night. She has had type 2 diabetes mellitus for the past 10 years and was started on insulin therapy 3 years ago due to suboptimal glycemic control (hemoglobin A1c 11%) on glipizide and metformin; metformin was continued but glipizide was stopped at that time. In addition to metformin, the patient currently takes 34 units of insulin glargine at bedtime and 6 units of insulin lispro before meals 3 times a day. She also eats a bedtime snack daily and has gained about 3.2 kg (7 lb) since insulin therapy was started. The patient has no chronic complications of diabetes mellitus. Medical history is notable for obstructive sleep apnea, hypertension, dyslipidemia, and obesity. She does not work, has a sedentary lifestyle, and does not use tobacco or alcohol.
Blood pressure is 140/90 mm Hg and pulse is 80/min. BMI is 34 kg/m². Jugular venous pressure is not elevated. There is trace pedal edema. The remainder of the physical examination is normal.
Hemoglobin A1c is 6.7%. Fingerstick blood glucose levels (mg/dL) for the 4 days prior to the office visit are as follows:

Which of the following is the most appropriate next step in management of this patient's diabetes mellitus?

Quizplus · Accepted Answer

11ec193a_97ae_b72d_853d_2f64f36a28fe_MD0002_00 Due to a progressive decline in insulin secretion, most patients with type 2 diabetes eventually require insulin therapy to maintain glycemic control. Insulin is recommended for those with poor control on oral antidiabetic therapy or those with marked hyperglycemia (eg, hemoglobin A1c >10%, fasting glucose >300 mg/dL, symptoms of hyperglycemia). Therapy should be titrated to maintain fasting glucose of 80-130 mg/dL, postprandial glucose <180 mg/dL, and A1c <7%. In addition, the ideal bedtime glucose is 90-150 mg/dL. In patients receiving basal-bolus insulin therapy, the dose of basal insulin should be reduced for preprandial and early-morning hypoglycemia, and the dose of bolus insulin reduced for post-meal hypoglycemia. This patient has good overall glycemic control but is experiencing early-morning (3:00 AM) hypoglycemia, most likely due to the effect of the long-acting insulin analog (ie, glargine). Reducing the glargine dose by 10%-20% should alleviate the early-morning hypoglycemia in this patient while still maintaining the fasting glucose levels at goal. (Choices B and C) Short-acting insulin analogs (eg, lispro, aspart, glulisine) have a faster peak and a shorter duration of action than regular human insulin. Lispro given at the evening meal can control postprandial and bedtime glucose without contributing significantly to early-morning hypoglycemia. Reducing lispro alone could lead to bedtime hyperglycemia without correcting the early-morning hypoglycemia; reducing both the lispro and glargine would alleviate the early-morning hypoglycemia but likely lead to significant bedtime hyperglycemia and suboptimal overall control. (Choice D) In patients with type 2 diabetes who require insulin, metformin can lower insulin requirements, decrease insulin-associated weight gain, and enhance glycemic control. In addition, metformin contributes little to the risk of hypoglycemia. Given the beneficial effects of metformin, it should generally be continued following initiation of insulin therapy. (Choice E) Increasing the amount of carbohydrate in the bedtime snack may decrease the risk of early-morning hypoglycemia but is likely to lead to more weight gain. Educational objective: Insulin therapy should be titrated to maintain fasting glucose of 80-130 mg/dL, postprandial glucose <180 mg/dL, and hemoglobin A1c <7% while avoiding hypoglycemia. In patients receiving basal-bolus insulin therapy, the dose of basal insulin is reduced for preprandial and early-morning hypoglycemia, and the dose of bolus insulin reduced for postmeal hypoglycemia. __________ References: Insulin therapy and hypoglycemia. (http://www.ncbi.nlm.nih.gov/pubmed/22575407)

A 51-Year-Old Woman Comes to the Office Due to Excessive