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Basal Insulin Case 2

CE / CME

The Role of Basal Insulin in the Modern Era of Diabetes Management: Interactive Case Challenge 2

Physician Assistants/Physician Associates: 0.75 AAPA Category 1 CME credit

Nurses: 0.75 Nursing contact hour

Physicians: maximum of 0.75 AMA PRA Category 1 Credit™

ABIM MOC: maximum of 0.75 Medical Knowledge MOC point

Released: October 26, 2023

Expiration: October 25, 2024

Steven V. Edelman
Steven V. Edelman, MD
CME/CE Information

Activity

Progress
1
Course Completed

History 
A 55-year-old woman is referred to endocrinology by her primary care provider because of inability to meet glycemic targets and frequent hypoglycemia. Her past medical history includes type 2 diabetes (diagnosed 4 years ago), obesity, and hyperlipidemia, and medications include metformin 1000 mg twice daily, canagliflozin 100 mg daily, glipizide ER 20 mg daily, dulaglutide 4.5 mg weekly, and neutral protamine Hagedorn (NPH) insulin 30 units at bedtime. She also takes rosuvastatin 20 mg daily and losartan 100 mg daily.

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Current Presentation 
The patient monitors her blood glucose using an intermittent continuous glucose monitoring (CGM) system. Her ambulatory glucose profile (AGP) shows an average glucose of 188 mg/dL, with a time in range (TIR) of 47% (goal >70%), a time above range (TAR) of 43% (goal <25%), and a time below range (TBR) of 10% (goal <5%). Her fasting blood glucose (FBG) average is 170 mg/dL. She reports tolerating her current medications and adherence, but she also reports symptoms of hypoglycemia 3-4 times weekly overnight and at various times throughout the day. These are confirmed with CGM and treated with a snack or glucose tablets. Her hypoglycemia frequency increased after self-titrating NPH to 30 units from 15 units per her provider’s instructions. She reports frustration with this, as she has noticed her blood glucose readings increase if she decreases her insulin. She also reports that NPH initially was chosen as a cost-saving measure because of the increasing expense associated with her medications. She reports losing 15 lb since starting dulaglutide 4 months ago and has been doing her best to improve her diet and exercise to continue her weight loss. Her current vitals are blood pressure 131/82 mm Hg, pulse 68 beats/min, height 5 ft 4 in, weight 189 lb, BMI 32.4 kg/m2. Recent labs show A1C 7.8% (goal <7.0%), urine albumin-to-creatinine ratio of 22 mg/g and an estimated glomerular filtration rate of 82 mL/min/1.73 m2. All other labs are within normal limits. She currently has insurance through her employer. 

Question 1

Which of the following interventions would be best for this patient at this time to improve blood glucose control and reduce hypoglycemia?