Case 1: John
A 58-year-old African American male presents for a routine diabetes follow-up appointment.
Click To Enter CaseCase 2: Carmen
A 16-year old Hispanic female presents to the office with a history of worsening fatigue over the last 6-12 months.
Click To Enter CaseCase 3: Betty
An 82-year-old Caucasian female presents to the office for a follow-up visit after routine blood work 2 weeks earlier showed a progressively increasing A1C level.
Click To Enter CaseCase 4: Robert
A 42-year-old male presents for his 3-month diabetes follow-up visit.
Click To Enter CaseCase 5: Lucy
A 52-year-old Chinese American female presents to her primary care provider for her 3-month routine diabetes follow-up
Click To Enter CaseInteractive Case Study Operating Instructions
- Optimizing Insulin Therapy: A Case-based Activity will present you with 5 interactive patient cases. You may choose to review each patient with type 2 diabetes in any order. Select a case from the left by clicking the 'Click To Enter Case' link. Once you enter the case and before answering questions, click on the patient’s tab to view his clinical presentation, medical history, and current medications.
- After reviewing each diabetes case, you will be asked about changes you would recommend to improve the patient’s glycemic control; you will be given the opportunity to compare your decisions with those of other participants and with the recommendations of our expert faculty.
- Each case will take approximately 30 minutes to complete.
- Use your mouse to click on your selected answers in each case.
- Upon completion of each case study, you will earn CME/CE credit and will be given the option to choose another case to earn more CEUs or exit the activity.
© Copyright 2012 CaringForDiabetes.com. All rights reserved.
| A1C | hemoglobin A1C |
| AACE | American Association of Clinical Endocrinologists |
| AADE | American Association of Diabetes Educators |
| ACCF | American College of Cardiology Foundation |
| ACCORD | Action to Control Cardiovascular Risk in Diabetes trial |
| ACE | American College of Endocrinology |
| ADA | American Diabetes Association |
| ADVANCE | Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified-Release Controlled Evaluation trial |
| ALT | alanine transaminase |
| AN | acanthosis nigricans |
| AST | aspartate transaminase |
| BID | twice daily |
| BMI | body mass index |
| BP | blood pressure |
| bpm | beats per minute |
| BUN | blood urea nitrogen |
| CAD | coronary artery disease |
| CBC | complete blood count |
| CGM | continuous glucose monitoring |
| CHF | congestive heart failure |
| CSII | continuous subcutaneous insulin infusion |
| CV | cardiovascular |
| DKA | diabetic ketoacidosis |
| DPP-4 | dipeptidyl peptidase-4 |
| EAS | European Association for the Study of Diabetes |
| ER | extended release |
| FPG | fasting plasma glucose |
| FSH | follicle stimulating hormone |
| GFR | glomerular filtration rate |
| HCP | healthcare provider |
| HDL | high-density lipoprotein |
| HEENT | head, eyes, ears, nose, and throat |
| I:C | insulin-to-carbohydrate ratio |
| IGC | intensive glycemic control |
| LDL | low-density lipoprotein |
| LH | luteinizing hormone |
| MDI | multiple daily injections |
| MI | myocardial infarction |
| NKDA | no known drug allergies |
| NPH | neutral protamine Hagedorn |
| PCP | primary care physician |
| PPG | postprandial plasma glucose |
| RRR | regular rate and rhythm |
| SMBG | self-monitoring of blood glucose |
| SU | sulfonylurea |
| T2D | type 2 diabetes |
| T1D | type 1 diabetes |
| T2D | type 2 diabetes |
| TDD | total daily dose |
| TID | three times daily |
| TZD | thiazolidinedione |
| UKPDS | United Kingdom Prospective Diabetes Study |
| VADT | Veterans Affairs Diabetes Trial |
| WNL | within normal limits |
Figure 1: John's Glycemic Control History
Figure 2: Acanthosis Nigricans
Figure 3: Betty's Glycemic Control History
Figure 4: AACE/ACE Algorithm for Glycemic Control
Figure 5: ADA/EASD Concensus Algorithm for Hyperglycemia Management in T2DM
Figure 6: Robert's 8-year Weight History
Figure 7: Robert's 8-year Glycemic Control History
Figure 8: Robert's 7-day CGM Report
Figure 9: Lucy's 10-year Glycemic Control History
Figure 10: Expected Insulin Levels Achieved Following Premeal Insulin Injection of Insulin Aspart Protamine/Insulin Aspart 70/30[1]
![Expected Insulin Levels Achieved Following Premeal Insulin Injection of Insulin Aspart Protamine/Insulin Aspart 70/30[1]](http://www.caringfordiabetes.com/optimizing-insulin-case-studies/resources/images/expected-insulin-levels-premeal.jpg)
Figure 11: Lucy's Estimated Daily Insulin Levels Compared to Meals
Figure 12: Time-action Profiles of Insulin Analogs[5]
![Time-action Profiles of Insulin Analogs[5]](http://www.caringfordiabetes.com/optimizing-insulin-case-studies/resources/images/time-action-profiles-of-insulin-analogs.jpg)
Table 1.1: John's Blood Glucose Logs
| Date | Fasting Glucose Levels (mg/dL) |
Before-Meal Glucose Levels (mg/dL) |
After-Meal Glucose Levels (mg/dL) |
Notes |
| Monday, October 11 | 110 | 160 | 205 | Cobb salad, unsweetened iced tea, bread |
| Tuesday, October 12 | 92 | Meeting, forgot to check | ||
| Wednesday, October 13 | 121 | 144 | ||
| Thursday, October 14 | 103 | 145 | ||
| Friday, October 15 | 90 | |||
| Saturday, October 16 | 108 | |||
| Sunday, October 17 | 113 | 180 | 239 | Spaghetti and meatballs |
| Tuesday, October 19 | 119 | |||
| Wednesday, October 20 | 88 | 149 | ||
| Thursday, October 21 | 105 | 147 | 240 | Grilled chicken, broccoli, salad?? |
| Friday, October 22 | 117 | 187 | Tuna salad, carrots | |
| Monday, October 24 | 122 | |||
| Thursday, October 27 | 89 | 155 | ||
| Friday, October 28 | 122 | |||
| Saturday, October 29 | 94 | 199 | Chicken wrap, apple |
Table 1.2: Onset, Peak, and Duration of Insulin Actions
| Insulina | Onset | Peak | Effective Duration |
Rapid-acting (prandial)
|
5-15 min | 30-90 min | < 5 h |
Short-acting
|
30-60 min | 2-3 h | 5-8 h |
Intermediate (basal)
|
2-4 h | 4-10 h | 10-16 h |
Long-acting (basal)
|
N/A | Relatively flat | Up to 24 h |
Premixed (biphasic)
|
10-15 min | Dual | 10-16 h |
|
10-15 min | Dual | 10-16 h |
|
30-60 min | Dual | 10-16 h |
|
10-15 min | Dual | 10-16 h |
|
30-60 min | Dual | 10-16 h |
a Assumes 0.1-0.2 U/kg per injection. Onset and duration may vary by injection site.
Table 1.3: Robert's Glucose Monitoring Log
| Day | Fasting AM | After Breakfast | Before Lunch | After Lunch | Before Dinner | After Dinner | Bedtime |
| 1 | 105 | 94 | 145 | 158 | 110 | ||
| 2 | 113 | 120 | 128 | 162 | 180 | ||
| 3 | 94 | 115 | 78 | 199 | 175 | 166 | |
| 4 | 119 | 106 | 134 | 118 | |||
| 5 | 54 | 220 | 230 | 198 | 105 | 260 | 188 |
| 6 | 160 | 145 | 110 | 140 | 128 | ||
| 7 | 67 | 130 | 165 | 158 | |||
| 8 | 127 | 119 | 51 | ||||
| 9 | 104 | 130 | 185 | 142 | 119 | ||
| 10 | 112 | 105 | 155 | ||||
| 11 | 58 | 110 | 45 | 260 | 220 | ||
| 12 | 68 | 160 | 145 | 120 | 80 | 150 | |
| 13 | 117 | 125 | 110 | ||||
| 14 | 109 | 130 | 95 | 124 |
Table 1.4: Lucy’s Blood Glucose log
| Day | Fasting AM (mg/dL) | 2-hr PPG (Breakfast) (mg/dL) | Before Lunch (mg/dL) | 2-hr PPG (Lunch) (mg/dL) | Before Dinner (mg/dL) | 2-hr PPG (Dinner) (mg/dL) | Bedtime (mg/dL) |
| 1 | 79 | 110 | 103 | 201 | 180 | 150 | 135 |
| 2 | 110 | 95 | 87 | 186 | 197 | 167 | 142 |
| 3 | 128 | 80 | 90 | 220 | 309 | 251 | 150 |
| 4 | 98 | 99 | 82 | – | 150 | 154 | 124 |
| 5 | 104 | 110 | 108 | 186 | 199 | 174 | 155 |
| 6 | 129 | 105 | 98 | 201 | 220 | – | 210 |
| 7 | 145 | 131 | 120 | 240 | 275 | 201 | 145 |
Table 1.5: Top 10 Sources of Nutrients (by Weight) in 4 Chinese Dietary Patterns6
Rank |
Green Water (Southeast China) |
Yellow Earth (Northwestern China) |
New Affluence (Higher Income) |
Western Adopter (Younger Individuals) |
| 1 2 3 4 5 6 7 8 9 10 |
Rice Vegetables Pork Fruit Vegetable oil Beer Wheat Fish, shrimp Eggs Starchy tubers |
Wheat Vegetables Rice Starchy tubers Other cereals Fruit Vegetable oil Eggs Pork Dairy products |
Vegetables Wheat Rice Fruit Dairy products Pork Eggs Starchy tubers Vegetable oil Fish, shrimp |
Vegetables Rice Fruit Wheat Beer Pork Eggs Soda, other beverages Vegetable oil Fish, shrimp |
Table 1.6: Lucy’s Dietary and Medication Schedule
| Time of Day | Insulin Administration | Food Consumed |
| 6:45 am | am insulin dose: 23 U | |
| 7:00 am | Breakfast with daughter-in-law: Cup of tea, small bowl of whole grain noodles, hard-boiled egg | |
| 1:00 pm | Lunch: Cooks for 4-year-old grandchild; eats a portion of what he eats | |
| 5:45 pm | pm insulin dose: 27 U | |
| 6:00 pm | Dinner: Large, home-cooked traditional Chinese meal (rice, vegetables, fruit, pork, shrimp, dairy) and sugar-sweetened carbonated beverage |
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