A 25-year-old man comes to the emergency department because of headache, palpitations, sweating, and irritability. He came directly from the health club, which he joined a few weeks ago. He states that after every exercise session during evening, before dinner, he develops similar symptoms and he gets symptomatic relief by consuming granola bars. He was diagnosed with type 1 diabetes mellitus eight years ago. He takes a combination of NPH and regular insulin before breakfast and supper. He states that he is very compliant with his insulin and meals. He does not have any other symptoms or chronic complications of diabetes. His blood pressure is 110/80 mmHg, pulse is 100/min, temperature is 36.7C (98F) and respirations are 14/min. He is slightly diaphoretic but completely alert and awake. His neurological examination is nonfocal. The rest of the examination is unremarkable. Which of the following is the most appropriate step to prevent further hypoglycemic episodes in this patient?

Question

A 25-year-old man comes to the emergency department because of headache, palpitations, sweating, and irritability.  He came directly from the health club, which he joined a few weeks ago.  He states that after every exercise session during evening, before dinner, he develops similar symptoms and he gets symptomatic relief by consuming granola bars.  He was diagnosed with type 1 diabetes mellitus eight years ago.  He takes a combination of NPH and regular insulin before breakfast and supper.  He states that he is very compliant with his insulin and meals.  He does not have any other symptoms or chronic complications of diabetes.  His blood pressure is 110/80 mmHg, pulse is 100/min, temperature is 36.7C (98F) and respirations are 14/min.  He is slightly diaphoretic but completely alert and awake.  His neurological examination is nonfocal.  The rest of the examination is unremarkable. Which of the following is the most appropriate step to prevent further hypoglycemic episodes in this patient?

Quizplus · Accepted Answer

Explanation: Exercise increases non-insulin-mediated glucose uptake by the exercising muscles. A lower dose of insulin is generally required during exercise. NPH is intermediate-acting insulin with peak actions after four to six hours of injection, and its effects can last up to 16 to 18 hours. Reducing the morning NPH insulin dose is likely to reduce this patient's hypoglycemic symptoms during the evening hours. Alternatively, the patient can eat granola bars (or any other source of glucose) before he exercises. Checking his blood sugar level before and after exercise to assess the impact of exercise may be of benefit. Avoiding insulin injection to the exercising limb may be helpful. All patients with type 1 diabetes with a blood sugar level of more than 250 and/or ketonuria should refrain from exercising. Acute effects of exercise on the blood glucose level are more commonly seen in patients with type 1 than type 2 diabetes. (Choice A) It is important to understand that normal individuals have basal insulin production even without food intake, while most type 1 diabetics are dependent on exogenous insulin administration for survival because they do not have endogenous insulin. Daily basal insulin should be provided to type 1 diabetics by two injections of intermediate acting insulin (NPH, lente) or one dose of long acting insulin (glargine). Discontinuation of the morning dose of NPH is likely to result in unwanted elevations of the blood glucose level in evening hours. (Choices B and D)The injection of regular insulin in the morning is responsible for controlling the blood sugar level of diabetics during breakfast. Lowering the regular insulin dose in the morning is likely to cause post-breakfast elevations of the blood sugar level. Similarly, lowering the dose of regular insulin before dinner is likely to result in unwanted elevations of the post-dinner blood glucose level. (Choice E)Oral hypoglycemic agents are not used in patients with type 1 diabetes mellitus. Educational objective: Hypoglycemic episodes during exercise in type 1 diabetics can be managed by decreasing the insulin dose, eating before exercising, and avoiding injections of insulin in the exercising limbs. Type 1 diabetics do not have endogenous insulin production and require basal insulin by injection of twice-daily NPH or one injection of glargine insulin at bedtime.

A 25-Year-Old Man Comes to the Emergency Department Because of Headache