Humalog only, no background

[EGVnurse]

Patient has had DM type 2 since 1998. About 239lb, 5'8". Severe muscular atrophy, wheelchair bound, difficulty raising hands above head, some issues with dexterity but takes most of his injections via pen in his abdomen.

Takes Humalog only (up to 185 units per day), looks like he's injecting 50-100 units per meal (even meals without carb). No background insulin. He estimates how much insulin to give himself based on nothing but experience.

No reported episodes of hypoglycemia in the past year and he knows the symptoms.

A1c in June was 8.1, 7.9 in March. August A1c is still pending.

MD hasn't ordered any changes to insulin and my gut says to let patient continue with this regimen, at least for now, because he's very knowledgeable about his own body and DM. We discussed site rotation and splitting doses, correct timing of insulin prior to meal. But I'm pretty surprised by his BG and A1c results. There is certainly room for improvement but the numbers are not outrageous by any means.

Anyone else had similar patient encounters? Advice? I want to give him a type of system for dosing himself but do not even know where to start. Thanks for any help.

[SteveDE]

My first question would be what are his pre- and post-meal blood sugars? What does his glucose do in the middle of the night or before breakfast? While the A1C is reasonable given his limited diabetes education and lack of a longer acting insulin, its still not at goal, and just as important, the A1C is only an average. So he could be 50 at certain times of the day and 350 other times of the day...that would average 200, but those swings in glucose are not healthy, versus someone that might range 160-240 throughout the day, their average would be 200, but their glucose is more consistent. I would highly suggest a long acting insulin to his primary medical provider for complete, consistent coverage. I don't see that he could be consistently at his optimal health, safest health without some basal insulin. I know everyone is different, but there should be a ratio in the neighborhood of 50/50 with basal and bolus.

No disrespect to anyone, but just because the MD hasn't ordered it, doesn't mean the patient doesn't need it. I would start with speaking with the MD, asking why he isn't on a long-acting insulin or possibly even recommending to the MD for patient to start a long acting insulin at a small dose, titrate up over the course of a couple of months and see how his A1C and glucose gets closer to a healthy range. Possibly even how he could decrease some of his Humalog insulin with the long acting insulin being started. Sounds to me like the patient has been dosing himself, has relatively "prescribed" his own dosing with little to no input by the MD...the MD needs to get involved.

[classicdame, MSN, EdD]

This regimen is outside the guidelines of both the ADA and the American Academy of Clinical Endocriniologists. We need insulin 24/7, not just when we eat. Whenever a regimen is not working it is time to step back and reconsider.

[meanmaryjean, DNP, RN]

Well, the first thing this patient needs is a new physician.......

[Mudwoman]

Something is wrong. Are you sure that he is seeing his physician every 3-6 months? Are you sure that the physician has not ordered additional diabetes medications? Is there an issue with him being able to afford the medications ordered? If he is on Medicaid: they do not cover Lantus at this time.

If he is injecting that much Humalog, then he is likely really, really insulin resistant. Part of that resistance is his muscle atrophy. The specialized cells that allow the uptake of glucose/insulin are in the liver and the skeletal muscle. He may not be aware of episodes of hypoglycemia if his autonomic nervous system has been affected by his diabetes. I have to wonder how often he tests his BG........if he even does. Is getting his testing supplies an issue for him?

He could benefit from Metformin or Januvia to help with insulin resistance. If cost is an issue, he could still benefit from an insulin like NPH that costs less than a basal insulin. Whatever is going on, this patient is self managing his diabetes (not very well), and needs to know there are more options that would give him better control. He also needs to work more closely with his healthcare team....doctor, educator, nurses, pharmacist etc. I'm shocked that even his pharmacist hasn't questioned such a huge amount of insulin usage.

There are some new Continuous Glucose Monitors coming on the market that are intended to be used by physician offices similar to a heart monitor. The CGM would be placed on the patient by the doc or nurse, and the patient could wear it for up to 7 days. The monitors take a BG reading every 5 minutes. This is an example of a patient that would really benefit from the information gained.....provided it was followed up with good education with him.