Insulin pump therapy (IPT) is emerging as an alternative to multiple daily injections in patients with uncontrolled type 2 diabetes (T2DM) needing to improve blood glucose (BG) control. However, IPT may increase the risk of hypoglycemia, particularly in patients with a long history of T2DM who cherish optimal metabolic control but are not accustomed to intense BG monitoring. We describe two patients with T2DM in whom improved BG control with IPT occurred at the expense of unchecked recurring hypoglycemia and hypoglycemia unawareness.
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A 65 year-old man with a 20-year history of T2DM on IPT and oral agents (HbA1c 5.4%), presented to the hospital for lower extremity cellulitis and a wrist fracture. He had sustained trauma from a fall of unclear etiology upon returning from a fishing trip. On the first night of admission, despite good intake and oral therapy hold, he experienced Level 2 hypoglycemia with hypoglycemia unawareness. Patient shared a history of several weeks of recurring hypoglycemia with BG in the 40-60 mg/dL range, occurring mostly at night. His insulin pump rates had not been adjusted in response to voluntary weight loss or to the marked reduction of his HbA1c. Patient acknowledged very sporadic BG monitoring. Although initially reluctant to change his pump settings, basal rates were decreased by 15%. BG remained within target until discharge. Patient was instructed to continue BG monitoring at home and to notify his physician if hypoglycemia recurred. Oral agents were held until his 1-week follow-up.
A 56-year old woman with a 13-year history of T2DM, complicated by chronic kidney disease, had been on IPT for almost 2 years prior to her hospital admission for Fournier’s gangrene. Her diabetes had remained poorly controlled (HbA1c 12.4%), but BG levels had significantly improved after recent pump rate adjustments. However, upon further questioning she conceded to no BG monitoring and to a history of recurring severe nocturnal hypoglycemia with hypoglycemia unawareness. Patient was initially reluctant to have IPT settings modified in the hospital, but a reduction of 33% from her pre-admit basal rate on the pump, and placement of a continuous glucose monitor, maintained adequate BG control without hypoglycemia recurrence at the time of discharge.
It is important that patients with T2DM and their providers be educated on the need of BG monitoring as a condition for IPT to reduce the risk of severe hypoglycemia and hypoglycemia unawareness. Providers should routinely inquire about hypoglycemia when evaluating patients on IPT, and adjust pump rates when HbA1c levels or BG monitoring reflect aggressive reduction.
Jordana Faruqi– Trainee Resident, University of Texas Medical Branch, The Woodlands, Texas
Kelly Ferguson– Diabetes Educator and Care Facilitator, University of Texas Medical Branch, League City, Texas
L. Maria Belalcazar– ASSOCIATE PROFESSOR-DIVISION OF ENDOCRINOLOGY, UNIVERSITY OF TEXAS MEDICAL BRANCH- GALVESTON
University of Texas Medical Branch
The Woodlands, Texas
I am a first year internal medicine resident interested in Endocrinology and Medical Education. I received my BS in Biochemistry, which sparked my interest in endocrinology.
Diabetes Educator and Care Facilitator
University of Texas Medical Branch
League City, Texas
Kelly Ferguson is a registered nurse serving as the Diabetes Educator and Care Facilitator at the University of Texas Medical Branch. She is a graduate student at the University of Texas Medical Branch's School of Nursing.