‫بسم اهلل الرحمن الرحيم‬

Nahda College
Program of Pharmacy
Department of Clinical Pharmacy
2020-2021

Diabetes cases
• 1. A 45-year-old obese female has just been diagnosed
with diabetes. Otherwise, she is healthy with no other
medical conditions. Her blood pressure today is 110/75
mm Hg; spot urine microalbumin ' 30; TC 180; HDL
32; LDL 122; TG 150. Based on ADA guidelines,
which should be started today?
• (A) Aspirin 81 mg daily
• (B) Pravastatin 10 mg daily
• (C) Lisinopril 10 mg daily
• (D) Irbesartan 150 mg daily
• The answer is B.
• Based on ADA guidelines, aspirin should be
initiated for primary prevention in women greater
than age 60; statin therapy should be initiated in
patients with overt CVD or any patient over the
age of 40 without overt CVD, but with other CVD
risk factors; ACEI and ARBs are recommended for
blood pressure control if necessary (not needed
here) and when urine microalbumin is ˃ 30.
• 2. A patient is currently on a regimen of   insulin lispro
protamine suspension and insulin lispro (Humalog Mix)
70/30, 24 units in the morning and 12 units in the evening.
Based on the following averages obtained from his blood
glucose meter, which would be the most appropriate
recommendation for his glycemic control today?
– Pre-Breakfast: 220 mg/dL
– Pre-Lunch: 110 mg/dL
– Pre-Supper: 90 mg/dL
– Bedtime: 108 mg/dL
– 3 am: 62 mg/dL
• (A) Increase evening dose of Humalog Mix to 15
units
• (B) Decrease evening dose of Humalog Mix to 10
units
• (C) Continue current regimen without changes
• (D) Increase morning dose of Humalog Mix to 28
units
• (E) Decrease morning dose of Humalog Mix to
20 units
• The answer is B.
• Increasing the morning dose will only lower the
lunch and supper readings further.
• Increasing the evening dose will lower the 3 a.m.
even more.
• This patient is most likely experiencing rebound
hyperglycemia (Symogyi) as evidenced by the
hypoglycemia at the 3 a.m. readings and elevated
fasting readings pre-breakfast.
• 3. A 222-lb male presents to the diabetes care team for routine
diabetes management. His fingerstick blood glucose value is
452 mg/dL (445 mg/dL on repeat) and his urine is negative for
ketones. Per clinic protocol, he may be treated in the office for
hyperglycemia. Which is the most appropriate treatment to
bring his blood glucose to a target of 120 mg/dL?
– (A) Glargine 20 units
– (B) Lispro 60 units
– (C) Aspart 30 units
– (D) Glulisine 11 units
– (E) Detemir 24 units
• The answer is D.
• The blood glucose needs to come down rapidly in office, thus he
would not choose glargine or detemir as agents due to their
longer onset of action. Lispro, aspart, and glulisine would all be
appropriate choices, but the dose should be based on the point-
of-care correction equation: ([Current blood glucose-Target
blood glucose]/CF).
• Steps to solve:
– 1. Weight in kg: Weight is 222lb = 101 kg
– 2. Determine TDD: (101)(0.6) = 60
– 3. Determine CF: 1800/60 = 30
– 4. Plug into equation: (452–120)/30 = 11 units
• 4. A 400-lb male has just been diagnosed with type
2 diabetes. His A1c is greater than 15% and his
kidney and liver function are normal. Which would
be the most appropriate initial agent for
monotherapy?
– (A) Metformin 850 mg q.d.
– (B) Pioglitazone 30 mg q.d.
– (C) Glargine 36 units q.d.
– (D) Liraglutide 0.6 mg q.d.
– (E) Glimepiride 4 mg q.d.
• The answer is C
• Metformin would typically be the initial agent of
choice in a patient diagnosed with type 2 diabetes.
• However, with this patient’s A1c greater than
15%, insulin is the most appropriate choice.
• Metformin can be started in addition to the
insulin, but not as monotherapy. Oral agents and
non-insulin injections will bring the A1c down no
greater than 1%.
• 5. A person newly diagnosed with T1DM will
need to start an insulin regimen. Based on her
weight of 100 lb, which would be the most
appropriate basal regimen?
– (A) Insulin detemir (Levemir) 13 units daily
– (B) Insulin glargine (Lantus) 27 units daily
– (C) insulin aspart (Novolog) 4 units three times daily
– (D) NPH 15 units once daily
– (E) U-500 1.5 mL twice daily
• The answer is A
• NovoLog is not a basal insulin and U-500 is
reserved for patients with severe insulin
resistance. NPH is dosed twice daily. Basal
insulin should be initiated at 50% of TDD.
TDD is 27 units, which gives 13.5 units as
basal.
• 6. Which formulation is the best
recommendation for a patient needing an
intravenous insulin infusion?
– (A) Regular insulin, U-500
– (B) Regular insulin, U-100
– (C) NPH insulin, U-100
– (D) Aspart insulin, U-100
– (E) Aspart insulin, U-400
• The answer is B
• Regular insulin, U-100 is the most logical
choice for an IV infusion. Aspart may be given
in an emergency preparedness situation, but
should not be given routinely due to the
additional cost above that of regular U-100
insulin.
• 7. A patient has been using continuous intravenous insulin
infusion at 0.8 units/hr with steady control after being diagnosed
with type 1 diabetes mellitus (T1DM). He is to be discharged
from the hospital with prescriptions for detemir and glulisine.
When is the most appropriate time to initiate the detemir?
– (A) 30 minutes prior to discontinuing the continuous insulin infusion
– (B) 1 hour prior to discontinuing the continuous insulin infusion
– (C) 2 hours prior to discontinuing the continuous insulin infusion
– (D) 1.5 hours aft er discontinuing the continuous insulin infusion
– (E) 3 hours aft er discontinuing the continuous insulin infusion
• The answer is C
• Long-acting insulin should be injected 2 hours
prior to discontinuation of a continuous insulin
infusion to allow adequate onset time.
8. Mr LG is a 47-year-old man with type 2 diabetes. He has
recently had basal insulin (insulin detemir) added into his other
diabetes medicines: metformin modified release 1 g twice a day
and gliclazide 80 mg twice a day. He complains of waking with a
headache and feeling ‘groggy’ and unrested in the morning. His
recent blood glucose readings have generally been very good
although his before breakfast readings are 10–13 mmol/L. He is
worried because he is feeling worse since he started insulin, even
though his blood glucose levels are much improved. He has made
an appointment with his primary care doctor. His primary care
doctor suspects nocturnal hypoglycaemia may be causing his
recent symptoms.
8.1 What is nocturnal hypoglycaemia?
Nocturnal hypoglycaemia is a low blood glucose reading that
occurs during the night. Definitions vary but it is generally
accepted that a reading of less than 3.5 mmol/L is
‘hypoglycaemia’. The normal symptoms of hypoglycaemia
may be missed if the patient does not wake. However, signs
noticed (often by partners) might include restlessness,
sweating and nightmares.
Symptoms experienced by the patient in the mornings
commonly include headache, lethargy and raised blood
glucose levels.
8.2 Why might nocturnal hypoglycaemia cause
raised blood glucose levels in the mornings?
Nocturnal hypoglycaemia may be caused by a
rebound rise in blood glucose levels due to the
‘somogyi effect’. This is the effect of the counter-
regulatory hormones, glucagon, cortisol,
adrenaline (epinephrine) and growth hormone,
which all increase glucose in response to low
levels.
8.3 How should it be treated?
Nocturnal hypoglycaemia once confirmed may be treated by
either having a bed-time snack, or by reducing the dose of
night-time insulin. I n the case of Mr LG, stopping his
sulphonylurea may also help resolve the problem. C are
must be taken when interpreting raised blood glucose levels
in the morning, since the obvious intervention would be to
increase the dose of night-time insulin. However when
nocturnal hypoglycaemia is the cause, increasing the insulin
dose would only make the problem worse and more
dangerous for the patient.
9. Mr PT is a 69-year-old man with longstanding
type 2 diabetes. He has recently noticed that his
right shoe has been rubbing his foot, which he
finds confusing since he has been wearing these
shoes for 6 months with no problems.
His whole left foot now looks red and swollen
and when Mr PT inspected it closely, he noticed
that there was a weeping sore. However, his foot
is not painful, so he does not feel too concerned.
9.1. What is the most likely reason that Mr PT
did not feel any pain associated with the sore?
Mr PT has probably developed sensory
neuropathy in his feet. This usually begins with
the loss of the sensation of vibration and then
may progressively lead onto the loss of sensation
altogether.
9.2. Why might Mr PT's shoe suddenly have started to
rub his foot?
The shape of the feet of people with diabetes has been
observed to change over time. This may be due to the
development of neuropathy which can weaken muscles
causing alterations to the shape of the arch of the foot
and toes. I n this case, we know that Mr PT has sensory
neuropathy since he is unable to feel the pain of the
weeping sore. It is likely that Mr PT may also have
motor neuropathy.