Bad Advice from Your Doctor? It Can Happen!

The Patient:

My patient William is a 48-year-old black male with a 20-year history of type 2 diabetes. Both of his sisters, both of his parents, and several of his aunts and uncles also have type 2 diabetes, which helps to explain why he got it at such a young age. He has a strong genetic tendency for type 2 due to his family history and his ethnicity. Type 2 diabetes can be more prevalent in Black, Hispanic, Native American, and Pacific Islander communities.

William came to see me for the very first time recently and told me that he takes 25 mg of Jardiance once a day, and 500 mg of metformin twice per day. He also takes 30 units of Lantus in the morning and 25 units in the afternoon. He takes Novolog on a sliding scale with meals, but only if his blood sugar is over 200 mg/dL. If his blood sugar is below 200 mg/dL at mealtime, he won’t take any fast-acting insulin. This was the instruction his primary care provider gave him, so he followed it. A good example of how PCPs need to become more educated about appropriate insulin therapy in their patients with type 2 diabetes.  As a result, William’s blood sugars have been high for years. Thankfully he’s been wearing the FreeStyle Libre 3 CGM, so he can consistently see his blood sugars day and night.

William’s 14-day CGM download is below:

As you can see from William’s download, his average glucose was 210 mg/DL, his sensor-derived A1c  (or GMI) was 8.3%, his glucose variability was 36%, and his time in range was only 39%. He didn’t have any time below range, but the rest of his numbers were all above 180 mg/dL.

Here is William’s 24-hour glucose profile:

The Problem:

William’s 24-hour glucose profile clearly shows that he does fairly well overnight, but when he has breakfast at approximately 6:00 am, his blood sugar shoots up to a peak – an average peak of over 250 mg/dL – and stays above 180 mg/dL past midnight with a lot of variability after meals.

The Solution:

It was quite clear that William needed a lot more insulin with meals, so I reeducated him on the proper way to administer mealtime insulin. I encouraged him to be proactive in treating his blood sugar, taking insulin 20 to 30 minutes before he eats and not just when he gets above 200 mg/dL.

The recommendations I gave to him were to start with a dose of 10 units for breakfast (I also gave him an adjustment algorithm based on his blood sugar before the meal) and to give the same correction amount of insulin with lunch and dinner. The correction factor will be to add one unit of fast-acting insulin for every 50 mg/dL above 200 mg/dL before each meal. I will see how he does, and add a pre-lunch and pre-dinner set dose just like for breakfast. I will probably make his correction amount more aggressive as I see how he does.

Because William’s blood sugar has been so high and he hasn’t had any blood sugars below 70 mg/dL, he has a low risk of hypoglycemia. He does have a FreeStyle Libre 3 CGM and we did make sure that his lower alert was set at 80 mg/dL just in case he reaches that level.

Lastly, I asked him to consider a hybrid closed-loop insulin pump because they work extremely well for people with type 2 diabetes on multiple daily injections. He did seem interested in trying it.

The Takeaway:

There are a few important takeaways from this case:

1. When type 2 diabetes runs so strongly in your family, you’re most likely going to get it, and at a younger age. However, there are so many more tools, medications, devices, and technology available now that can help you lead a long and healthy life…even longer than someone without diabetes.
2. William’s pancreas is not working well any longer, and he needs insulin just like someone with type 1 diabetes. This is not uncommon as type 2 diabetes is a progressive condition. William needs a basal dose (long-acting) of insulin as well as fast-acting doses with every meal. Once someone gets extremely high like he’s been getting every day, it’s very difficult to get those numbers down. It’s much better to be proactive and prevent them from going up in the first place than to treat the highs.
3. Keep engaged in diabetes education and keep learning about the latest in diabetes management. Don’t always believe everything your doctor tells you…unless of course your doctor is me!