AUTHORS
Diya Manavalan, PharmD, Pharmacy Resident, Touro University California College of Osteopathic Medicine, Primary Care Development, Vallejo, CA
Cindy Wen, PharmD, Touro University California College of Pharmacy, Vallejo, CA
Clipper F. Young, PharmD, MPH, CDCES, BC-ADM, BCGP, APh, Associate Professor and Clinical Pharmacist, Touro University California College of Osteopathic Medicine, Primary Care Department, Vallejo, CA
PEER REVIEWER
Vida Farhangi, MD, FACP, Diplomate in Obesity Medicine, Director of Outpatient Residency Clinic, Florida State University-Sarasota Memorial Hospital, Sarasota, FL
A 52-year-old Caucasian male, who was diagnosed with latent autoimmune diabetes in adults (LADA) at age 35 years, was referred to our diabetes center for further diabetes management. At the time he was diagnosed, his hemoglobin A1c was at 17.9%; the A1c obtained during his initial visit at the diabetes center was at 12.1% (May 2020). His past medical history includes depression, erectile dysfunction, hyperlipidemia, hypertension, and lumbar radiculitis.
Before using diabetes technology, his medications included:
- Humalog, 6-8 units for breakfast; 20 units for lunch and dinner (carbohydrate ratio: 5 units of insulin per 15 grams of carbohydrate)
Glucometer data (June to July 2020):
- Before breakfast: 122 mg/dL to 259 mg/dL
- Before lunch: 100 mg/dL to 158 mg/dL
- Before dinner: 98 mg/dL to 196 mg/dL
- Bedtime: 93 mg/dL to 249 mg/dL
He reported experiencing two episodes of hypoglycemia in the early morning, thus he self-reduced his basal insulin dose. He also expressed feeling comfortable titrating his insulin regimen, including both insulin and mealtime insulin, based on his fingerstick blood glucose readings. In addition, he would like to start on an insulin pump without a tube attached.
After Starting Diabetes Technology
The patient chose Omnipod, pairing with Dexcom G6. The pump settings are summarized below (after a telephone encounter on March 23, 2021):
- Basal rate: 2.2 units per hour (12 a.m.- 5 a.m.); 2.1 units per hour (5 a.m.-12 a.m.)
- Insulin to carbohydrate ratio: 1 unit per 6 grams
- Insulin sensitivity factor: 1 unit per 25 mg/dL
The following table shows his most recent sets of continuous glucose monitoring (CGM) summary data:
Time Frame |
March 10-23, 2021 |
March 27-April 9, 2021 |
Average Glucose |
203 mg/dL |
188 mg/dL |
Standard Deviation |
67 mg/dL |
61 mg/dL |
Time in Range (Target Range: 70 mg/dL to 180 mg/dL) |
> 180 mg/dL: 57% In range: 43% < 70 mg/dL: 0% |
> 180 mg/dL: 47% In range: 53% < 70 mg/dL: 0% |
His most recent A1c was at 8% (January 2021).
Thoughts on Progression: Telephone Encounter on April 9, 2021
Assessment: After the last phone encounter, the patient’s average glucose improved from 203 mg/dL to 188 mg/dL; time-in-range for glucose levels improved from 43% to 53% without experiencing hypoglycemia. Since the patient still had a pattern of significant elevations between 12 a.m. and 6 a.m. (reflected in 47% of the time above 180 mg/dL), consider increasing basal rate between 12 a.m. and 5 a.m. by 10% to optimize glycemic management.
Plan:
- Basal rate: 12 a.m.-5 a.m.: 2.4 units per hour (increased from 2.2 units per hour)
- 5 a.m.-12 a.m.: 2.1 units per hour
- Bolus settings: Leaving all the settings below the same, the patient most likely will need to change his carbohydrate ratio in the future to help manage postprandial high
- Insulin to carbohydrate ratio: 6 grams/unit
- Sensitivity: 25 mg/dL/unit
- Active insulin time: 4.0 hours
- Glucose target: 120 mg/dL
- Glucose correction threshold: 150 mg/dL
