A 35-year-old man comes to the physician with complaints of dizziness and fatigue. These episodes occur immediately after he exercises on the treadmill for 30 minutes, and are accompanied by shaking and sweating. He has a history of type 1 diabetes mellitus and takes insulin glargine once daily at breakfast and pre-meal injections of insulin aspart. The patient checks his blood glucose every day prior to breakfast; the usual range is 110-140 mg/dL. His last hemoglobin A1C was 7.2%. He has no other medical problems.
Which of the following is the best next step in management of this patient?

Question

A 35-year-old man comes to the physician with complaints of dizziness and fatigue.  These episodes occur immediately after he exercises on the treadmill for 30 minutes, and are accompanied by shaking and sweating.  He has a history of type 1 diabetes mellitus and takes insulin glargine once daily at breakfast and pre-meal injections of insulin aspart.  The patient checks his blood glucose every day prior to breakfast; the usual range is 110-140 mg/dL.  His last hemoglobin A1C was 7.2%.  He has no other medical problems.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Hypoglycemia is a common side effect of insulin therapy. Risk factors for hypoglycemic episodes include excessive insulin dose, very strict glycemic control, excessive physical activity, and decreased food intake. Hypoglycemia also appears to be more common in patients with type 1 as compared with type 2 diabetes. Patients on insulin therapy (or insulin secretagogues) should monitor blood glucose before, during, and after exercise. Strenuous exercise should be avoided in the presence of significant hyperglycemia (>250 mg/dL) or ketosis. Guidelines for the management of blood glucose during exercise include: Adequate fluid intake Monitoring and documenting blood glucose before, during, and after exercise for subsequent sessions For low blood sugar (<100 mg/dL) before and during exercise, 15-30 g of rapidly absorbed carbohydrates (eg, hard candies, juice) are helpful For delayed post-exercise hypoglycemia (4-8 hours after), slowly absorbed carbohydrates (eg, dried fruit, nuts) are recommended Decreasing insulin dose prior to exercise by 30% Adequate fluid intake Monitoring and documenting blood glucose before, during, and after exercise for subsequent sessions For low blood sugar (<100 mg/dL) before and during exercise, 15-30 g of rapidly absorbed carbohydrates (eg, hard candies, juice) are helpful For delayed post-exercise hypoglycemia (4-8 hours after), slowly absorbed carbohydrates (eg, dried fruit, nuts) are recommended Decreasing insulin dose prior to exercise by 30% This patient with hypoglycemia related to exercise would benefit from 15-30 g of rapidly absorbed carbohydrate before (15-30 minutes) and during (every 30 minutes) exercise, as well as adequate fluid intake. (Choice A) Diabetics are encouraged to exercise at least 150 minutes/week at moderate intensity to improve glycemic control, lose weight, and improve cardiovascular health. Decreasing physical activity is generally not recommended as the first option for preventing hypoglycemic episodes in insulin-treated diabetics. (Choice B) Decreasing the dose of glargine would be effective in reducing nocturnal hypoglycemia. However, this patient's hypoglycemic episodes are related to exercise, not glargine administration. In addition, reductions in basal insulin will most likely worsen his overall glycemic control. (Choice D) Increasing the dose of aspart insulin is likely to increase the risk of hypoglycemia. (Choice E) The risk of hypoglycemia with long-acting basal insulin analogues such as glargine or detemir is much lower compared to NPH insulin. In addition, NPH generally must be administered twice daily to achieve adequate basal insulin coverage due to its shorter duration of action. Educational objective: Hypoglycemic episodes may occur in patients on insulin therapy (or insulin secretagogues) during and after exercise. These can be avoided by adequate hydration, frequent monitoring of blood glucose, consumption of rapid-acting carbohydrates before and during exercise, and, if necessary, insulin dose adjustment prior to exercise. __________ References: Insulin therapy and exercise. (http://www.ncbi.nlm.nih.gov/pubmed/21864755) Barriers of physical activity among patients with type 1 diabetes. (http://www.ncbi.nlm.nih.gov/pubmed/18689694)

A 35-Year-Old Man Comes to the Physician with Complaints of Dizziness