Interactive diabetes case 6: Uncontrolled diabetes in a 64-year-old patient treated with insulin – A4

ANSWER — Correct.

The use of insulin three times a day results in an improvement in metabolic control. The glycated hemoglobin (A1C) value falls to 9.3 percent, and symptomatic insulin reactions become less frequent. However, glucose control remains unsatisfactory based on the A1C level and on continuing lability of blood glucose values, predominantly before supper, when values fluctuate between 41 and 331 mg/dL (2.3 to 18.4 mmol/L).

What do you do now?

●Change the patient's NPH insulin doses to a single dose of glargine insulin 14 units at bedtime and continue the aspart insulin as before to provide a more stable basal insulin level. (See "Interactive diabetes case 6: Uncontrolled diabetes in a 64-year-old patient treated with insulin – B1".)

●Change the patient's NPH insulin doses to a single dose of glargine insulin 14 units before breakfast and continue the aspart insulin as before to provide a more stable basal insulin level. (See "Interactive diabetes case 6: Uncontrolled diabetes in a 64-year-old patient treated with insulin – B2".)

●Add a dose of aspart insulin before lunch using the same sensitivity and correction factors to provide a more intensive insulin regimen. (See "Interactive diabetes case 6: Uncontrolled diabetes in a 64-year-old patient treated with insulin – B3".)

●Refer the patient to a registered dietitian for a detailed review of the patient's diet, with particular attention to counting of carbohydrates and review the patient's physical activity to see whether variations in diet and/or activity explain persistent variability of glucose values. (See "Interactive diabetes case 6: Uncontrolled diabetes in a 64-year-old patient treated with insulin – B4".)