March 22, 2023

I guess just a quick diabetes case and review this is a example that i wanted to share with you guys it actually happened to me this is a few years ago now but this was back in 2015 i had an 88 year old female come into the emergency department because her insulin pump malfunctions so what do people do an insulin pumps malfunction well the first thing they do is they

Ask the pharmacy of what to do and we kind of throw up our hands because we don’t really deal with them either so it’s sort of a interesting situation because i don’t think it’s really widely taught what you do with an insulin pump but just some information for you guys in case you happen to run into a case with a malfunction pump or a pump you need to interrogate

Or something like that what some things to know is first of all i would recommend understanding how your site works and if you have access to a diabetes educator or diabetes specialist or something like that that could come down and review it because those people are invaluable in the cases like this but if you have access to a medical record you should be able

To find what pump settings there so for example i went into this patients chart and i found that a month ago she had a chart or clinic visit office visit and they put in all four pump information so our pump type what type of insulin so she’s using human q here which is insulin list pro and the rates there so you can see her basal rate changes throughout the day

Insulin to carbohydrate ratio one unit per 23 grams of carbohydrates at 24 hours insulin sensitivity is their target blood glucoses are their active insulin and then kind of the plus or minus is their percentage of basal and bolus so it really gives you all the information and so with that you can kind of see oh sorry tdd stands for total daily dose so that’s how

Much insulin she’s getting on a daily basis about eighteen point eight units plus or minus you know a unit so that’s really helpful information when you have a patient who comes in and they have a pump that’s malfunctioned and you want to know first of all like how much insulin do i need to replace on this person in the mean time before they can get their pump

Repaired medtronic is pretty good about sending new pumps pretty quickly but you do sometimes have a window of time where you need to supplement with thing else so one thing i would say is the first question you should probably ask yourself is why she on a pump you know might be you might think well she’s of course a type 1 diabetic could have in fact in this case

This patient was actually a type 2 diabetic patient who was managed quite well with just a small amount of insulin a day and instead of doing regular injections she elected to do an infusion pump so well it’s more common to see a continuous infusion pump on a type 1 diabetic you can certainly use them in type 2 patients so that’s a really important thing think

About as well what you know can she go without obviously a type 1 patient would certainly need some sort of intensive regimen to back up their their lack of pump but a patient who is type 2 could get by with maybe some other options so we talked about a lot of different solutions i worked with her physician in the emergency department we talked through you know

Do we do a sliding scale mealtime do we do a basal and they’re kind of working up a couple different rates and eventually we came to two choices we had the easy choice which was let’s just give her some basal insulin let’s give her you know 10 units of lantis or 15 units atlanta store and remember what we ended up doing a day and then call it good and then have her

Follow up with getting a new pump in the you know and the next week i believe this was of course on a friday night or saturday morning right so it’s something where you know business hours i can apply it you can’t just go and get a new pump very easily or at least she might not be able to get one until monday when it can be delivered to her house or picked up from

Somewhere so that’s actually what we elected to do now you should could certainly get a little more complicated and do with meal time but then you have to calculate sliding scales and educate the patient the patient’s used to using a pump she’s 88 so just you know how long has she been using the pump does she you know remember how to do all the things i’m not just

Saying that because she’s 88 but in general like i think me personally if i’d been using a pump for 5-10 years and somebody told me that i had to go back to sliding-scale and carb counting i’d probably be like no thanks but of course you have to do some of that anyway with a pump but with the individual injections it’s just so much more complicated and there’s so

Much more preparation and things like that so it’s a lot more work so for an easy solution for this patient i think we made the right choice by just giving her some basal insulin for the next couple days we give her a large gene patent or atlanta’s pen and discharged her from the er we did consult with our diabetes educator on-site as well other scenarios so if her

Blood glucose was over 500 upon admission it wasn’t in this case you know she was actually pretty well controlled for the most part but if she was looking in at like a high elevated blood glucose you would either think maybe dka or hhs and then you’re gonna go down a more advanced treatment algorithm and decide whether or not you need to give iv insulin much remember

Iv insulin the only insulin we can give iv at least that’s well studied is regular insulin so in those patients you may be considered an iv bolus of regular insulin maybe starting her on an insulin drip and then admitting her to the hospital we have something i’m going to talk about this a little bit more with critical care and emergency medicine in the summer but

We have something we called endo tool which is endo endo short for endocrine not endoscopy i think about that when i hear that for some reason but it’s called endo a tool and basically as a provider all you have to do is order endo tool and then it’s all nursing run protocol so it has all your lab checks in there it has your insulin it also has your dextrose bolus

In case you need to you know compensate and we’ve actually found really successful management with that it’s all protocol driven based on labs and data and stuff like that so from fred or staff but it’s pretty easy it’s like ordering a heparin protocol you just sort of order it and then you can kind of watch from a distance if you can get a new pump for two weeks

I would say that’s probably a situation where first of all you won’t ever follow up with primary care as soon as you can to see what would be the best option for her do they want to go with the more intensive insulin regiment for those two weeks versus just the simple basal houki prescriber all right a couple review questions this one is the first question here

Which of the following medication regimens would be preferred to start a newly diagnosed type one diabetic patient and what other information would you want to know that’s more of a rhetorical question but let’s focus on the multiple choice aspect so a second if you want to pause or whatever and think about it so of course one the newly diagnosed type one diabetic

Brings the bell that you you have to use insulin so glargine plus s part gives you your long-acting plus your meal time every other option here is just for type well include something that’s only for type two diabetes right so metformin isn’t for type 1 and glp in this case examine type is not for type 1 diabetic stick to only second question we’ve got mt a 46 year

Old male has got hypertension and type 2 diabetes he’s big nine he knows recently and started on metformin additionally he has been working on improving his diet and exercising more after five months of these changes his a1c is eight point seven what would be the best option today you got again if you want to pause or something but you’ve got four choices here and

First of all knowing a1c goals i’d say have a good idea i’d give you a pretty i give you an a1c it should be pretty obvious or i’ll just tell you it’s in goal or out of goal but you know you should be able to know i think right off the bat if i gave you a one c 10 but that’s pretty high or if i gave you an a1c of six that’s in range so no those extremes they won’t

Kind of test you on those weird middle ground ones between the guidelines where they disagree but best option here so he’s on metformin he’s working on his diet exercising more so those are kind of the key points here so what’s the best one so a one c isn’t that goal right eight point seven is still pretty high all these options are technically okay so this come

Kind of comes into play and this wouldn’t be a question i would ask you on the test i would give you a little bit more than this but for discussion purposes you know what more information would you want to know adding basal insulin would be an option certainly and that’s something that again historically has been some a choice that’s been second lime but again

The endocrinology group decided that that’s not the best choice anymore for a younger guy he’s you know 46 i didn’t give you any information to say his got renal insufficiency i would say if his insurance covers it kanna glyph losen or one of your sglt2 would be probably one of the best options to consider first of all it’s got some cardiovascular related that if

It’s potentially it also has some weight loss associated with it and assuming his kidneys work fine it’s a nice option to add second line now it is expensive so whether or not insurance can pay for it or not is a great question but that’s probably the way i would go with it now again insurance might say nope we want you to try glipizide first and the ata would say

Glipizide is fine too and i personally don’t have a big issue with somebody prescribing glipizide just you know using this question as a discussion point to say what do the guidelines say and what’s different and to get you in the mindset of thinking about these drugs as all being acceptable options for the most part but deciding which one’s best for the patient

So in this case i think bea’s probably the best because he’s younger if i gave you he was read had renal insufficiency then you probably would think of insulin or glipizide or renal insufficiency plus he refuses any injectables then you know that takes you right to glipizide all right that’s the last question the cases are posted feel free to go through those and

Email me any questions you have thanks

Transcribed from video
Exam II Review By Chad Peterson