You work in the diabetes mellitus (DM) center at a large teaching hospital. The first patient you
meet is K.W., a 25-year-old Hispanic woman, who was just released from the hospital 2 days ago
after being diagnosed with type I DM.
Nine days ago, K.W. went to see the physician after a 1-month his...
You work in the diabetes mellitus (DM) center at a large teaching hospital. The first patient you
meet is K.W., a 25-year-old Hispanic woman, who was just released from the hospital 2 days ago
after being diagnosed with type I DM.
Nine days ago, K.W. went to see the physician after a 1-month history of frequent urination,
thirst, severe fatigue, blurred vision, and some burning and tingling in her feet. She attributed
those symptoms to working long hours at the computer. Her random glucose level was 410
mg/dL. The next day her laboratory values were as follows: fasting glucose 335 mg/dL,
hemoglobin A1C (HbA1c) 8.8%, cholesterol 310 mg/dL, triglycerides 300 mg/dL, high-density
lipoprotein (HDL) 25 mg/dL, low-density lipoprotein (LDL) 160 mg/dL, ratio 12.4, and creatinine
0.9 mg/dL. Her body mass index is 37.6. Her blood pressure (BP) is 160/96 mm Hg. She was
admitted to the hospital for control of her glucose levels and the initiation of insulin therapy
with carbohydrate (CHO) counting. After discharge, K.W. has been referred to you for
comprehensive education. You are to cover four basic areas: pharmacotherapy, glucose
monitoring, medical nutrition therapy (MNT), and exercise.
1. K.W. was started on sliding scale lispro (Humalog) four times daily and glargine (Lantus)
insulin 30 units at bedtime. What is the most significant difference between these two insulin
therapies?
The difference is their onset, peak, and duration. Lispro is a fast-acting insulin analogue with
an onset of action within 15 minutes, a peak effect of ½ to 1 hour, and a duration of 3 to 4
hours. Patients using lispro are cautioned not to take it until they sit down to eat or no
sooner than 10 minutes before eating. Food intake must match insulin administered to avoid
hypoglycemia. The short duration necessitates frequent administration. Glargine (Lantus) is
basal insulin with no peak effect and a longer than 24-hour duration of action. The risk of
hypoglycemia is minimal. Its long duration allows for once daily injection.
2. K.W. says she knows people who “only take 2 shots” because they are on NPH and regular
insulin and wants to know why she can't do that. Explain the advantages of using the glargine
(Lantus) and lispro (Humalog) insulin regimen.
The most effective insulin regimen, with the best glycemic control, is the one that most
closely mimics normal insulin production by the body—the basal-bolus regimen, using lispro,
a bolus insulin, before meals and a long-acting basal background insulin once or twice a day.
Other advantages to this regimen are less weight gain and less nocturnal hypoglycemia
because glargine insulin provides steady-state coverage.
3. What specific points would you include regarding managing insulin therapy? Select all that
apply.
a. Store unused insulin in the freezer.
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