Question

COMPLAINT: "My blood sugars have not been very good lately. I’m doing everything I am supposed to be doing."

HISTORY: A 24-year-old male patient comes to your primary care clinic to establish care. He has type 1 diabetes mellitus diagnosed at age 11. He has not seen a provider in about 9 months. Currently, he is taking NPH insulin 30 units bid (8 a.m. and 6 p.m. with 10 units Humalog before each meal. He does not use tobacco products but does drink alcohol on the weekends. He reports checking blood glucose (BG) levels three to four times daily but did not bring his glucose log or meter. He reports his fasting blood sugar runs 150 to 190 and prandial glucose readings are 140-250. He reports hypoglycemic episodes one to two times week. He exercises intermittently but is not on a regular schedule. He does not eat on a regular schedule every day although he says he knows that he should. He works at a light-activity job 8 hours daily. His height is 5’10" and he weighs 200 pounds. His blood pressure is 128/78 mm Hg and is pulse is 76 and regular. A random fingerstick glucose is 240 and point of care A1c is 9.8. Fasting chemistry and lipid panels, thyroxine (T4) and thyroid-stimulating hormone (TSH), and random urine for microalbumin are ordered.

ASSESSMENT:

1. Fasting BG: 203

2. Lipid profile: high-density lipoprotein 55; low-density lipoprotein 103; triglycerides 180; total cholesterol 209

3. Thyroid within normal limits

4. Creatinine 1.0; albumin 5.0

5. Microalbumin 17

Your patient is uncontrolled type 1 diabetes mellitus and borderline hyperlipidemia, with normal blood pressure and body weight.

1. How would you treat this patient?

2. What would initial instruction include?

Answer 1

1. Treatment

Type 1 diabeteic patients needs lifelong insulin therapy.

Types of insulin are many and include:

• Short-acting (regular) insulin
• Rapid-acting insulin
• Intermediate-acting (NPH) insulin
• Long-acting insulin

Patients with type 1 diabetes typically require an insulin dosage of 0.5 to 1.0 unit per kg per day.

Total Daily Insulin Requirement (in units of insulin)
= Weight in Pounds ÷ 4

So that would be 200/4= 50 units of insulin/day

Basal/background Insulin Dose
= 40-50% of Total Daily Insulin Dose which would be 20-25 units where long acting insulin such as lente insulin can be used.

the rest of the insulin can be divided pre meals to provide better post pranidal insulin levels where short acting such as insulin lispro, aspartate, glulisine.

In addition to this the patient should be advised to take meals at regular intervals at a designated time and schedule, otherwise he stands no benefit from insulin infusion. Also the patient should be advised to follow a regular exercise regimen which includes walking for a period fo 30-40 mins 4-5 times a week. Avoid alcohol and cigarette smoking as well,

Hyperlipidemia- Statins form the main basis of treatment

Atorvastatin (Lipitor), 10 to 80 mg daily

Fluvastatin (Lescol), 20 to 80 mg daily at bedtime

Lovastatin (Mevacor), 10 to 80 mg daily at bedtime

Pravastatin (Pravachol), 10 to 80 mg daily

Fibrates

Fenofibrate (Tricor), 48 to 145 mg daily

Niacin

OTC immediate-release niacin, 0.5 to 2 g two or three times daily

Fish oil contains high amounts of the essential fatty acids docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA); these acids also are known as omega-3 fatty acids. A systematic review showed that fish oil is effective at lowering triglyceride levels.9 Fish oil with 2 to 4 g of total EPA/DHA daily can lower triglyceride levels by 30 to 50 percent.

2. the inital instructions would include as i have already talked about earlier but will paste the answer here as well

The patient should be advised to take meals at regular intervals at a designated time and schedule, otherwise he stands no benefit from insulin infusion. Also the patient should be advised to follow a regular exercise regimen which includes walking for a period fo 30-40 mins 4-5 times a week. Avoid alcohol and cigarette smoking as well. consume fats which are rich in polyunsaturated fatty acids. Adopt a healthy diet which contains 40-50% of carbohydrates, 20-25% fats and rest proteins.