Question 1:

Assessment

Sensor data:

  • Average blood glucose 214 mg/dL ±74 mg/dL
  • Worn ∼4 days/week
  • Hyperglycemic alarms 4.3 time/day
  • Overall, blood glucose measurements are trending high throughout the day
  • Overnight (8:00 PM–8:00 AM): blood glucose trends up
  • Post-prandial period: occasional low blood glucose measurements after meals
  • Hypoglycemic episodes more commonly preceded by issues with food boluses

Pump data:

  • Changes sites every 2.5–3 days
  • Basal/bolus ratio 44/56 units
  • Total daily dose of insulin XXX

Fingerstick blood glucose data:

  • Hyperglycemic throughout the day

Conclusion

  • Patient needs to use sensor more frequently
  • Accurate carbohydrate counting
  • Proper timing of insulin delivery to carbohydrate intake
  • Given the elevated A1c and avergae blood glucose >200 mg/dL, and insulin delivery is tilted more heavily towards bolus, increase basal settings by 10–20% and reassess

Question 2:

Assessment

  • Basal insulin, on average, is >50%
  • Patient uses 3 different patterns of basal insulin
  • Manual suspension for 2 hours every morning (shower, etc.)
  • 4 hypoglycemic episodes in 2 weeks, around dinner time
  • Blood glucose: pre-breakfast is mostly within target; pre-lunch is >50% above target; pre-dinner shows hypo-, hyper-, and euglycemia; not enough measurements at bedtime

Conclusion

  • Consider temporary basal in the evening time, as the hypoglycemic episodes may be related to increased activity
  • Accurate carbohydrate counting (especially with breakfast), as the pre-lunch measurements are higher >50% of the time
  • As the A1c is within target, initial focus should be prevention of hypoglycemia
  • If the basal insulin pattern is changed for any reason (stress, infection, exercise, steroids, etc.), remember to go back to the usual setting once the stressor is resolved

Question 3:

Assessment

  • Fingerstick blood glucose measurements are above target, but insufficient on many days
  • Carbohydrate intake is not consistently entered into the pump
  • Numerous basal programs noted
  • Basal/bolus insulin ratio is overall adequate—close to 50/50
  • CGM shows a "yo-yo" pattern: low(er) blood glucose measurements are typically preceded by high blood glucose measurements and a bolus insulin injection
    • Also, glucoses are typically out of range following hypoglycemic episodes
  • Patient does not check fingerstick blood glucose when the CGM reads low: numerous low blood glucose measurements are noted on CGM tracings, but none are seen on fingerstick readings

Conclusion

  • Accurate counting of carbohydrates and entering them into the pump will ensure appropriate delivery of bolus insulin
  • Check blood glucose by fingerstick measurement when the CGM alarms for low or high glucose
  • Patient should be educated on appropriate treatment of hypoglycemia
  • Delete basal programs which are not used
  • Reduce insulin sensitivity factor to prevent hypoglycemia and increase pramlinitide to 30 μg three times a day before meals to reduce post-prandial spikes

Question 4:

Assessment

Sensor data:

  • Blood glucose measurements tend to rise after 4:00 PM on most days, regardless of food intake, and continue to rise after most dinners, until bedtime

Fingerstick blood glucose data:

  • Pre-meal and bedtime blood glucose measurements tend to be high
  • There is more variability in the pre-lunch measurements
  • Occasional insulin boluses are seen during the middle of the night, but no concomitant blood glucose is seen
  • Although blood glucose measurements pre-breakfast are not at goal, they tend to be lower than bedtime measurements, on average

Conclusion

  • Accurate carbohydrate counting pre-breakfast and proper timing of bolus insulin to meals
  • Increase insulin/carbohydrate ratio at dinner
  • Increase basal insulin rate between 4:00–9:00 PM
  • Encourage the patient to check blood glucose when CGM reads high (even if it is the middle of the night) and adjust bolus insulin using fingerstick measurements rather than CGM readings
  • Once the pre-dinner measurements are closer to target, consider decreasing overnight basal insulin