1. Using Pre-Mixed Insulin Case Study Lucia M. Novak, MSN, ANP-BC, BC-ADM The Diabetes Institute Walter Reed Army Medical Center, Washington, DC Adjunct Assistant Professor, Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, MD

2. Premixed Insulin Case Study ~John~  72 yo African American man  Presents with complaint of frequent episodes of weakness and “nervousness” in the evening  His wife died 1 year ago and he now lives alone  His schedule is erratic, some days he wakes up at 6AM, other days he sleeps until 10AM because he has been up late watching TV.  On the days he wakes up late, will have late breakfast, will skip lunch and eat an early dinner.  Most of his meals are “frozen TV dinners.”  He will have a snack when he gets home because he feels nervous  His exercise consists of an evening walk he likes to take after he eats dinner

3. Pertinent History  Past Medical History: Type 2 Diabetes Mellitus (15 years) Type 2 Diabetes Mellitus (15 years) Coronary Artery Disease (MIx1 15 years ago, 2vCABG) Coronary Artery Disease (MIx1 15 years ago, 2vCABG) Hypertension (20 years) Hypertension (20 years) Dyslipidemia (20 years) Dyslipidemia (20 years) Benign Prostate Hyperplasia (10 yrs) Benign Prostate Hyperplasia (10 yrs)  Social History: Widower, no children Widower, no children Active in his retirement community Active in his retirement community Former smoker, quit 15 years ago Former smoker, quit 15 years ago Occasional beer Occasional beer

4. DM Management  Current: (2 yrs) PreMixed 70/30 Human Insulin (NPH/REG) PreMixed 70/30 Human Insulin (NPH/REG) 18 units “in the morning”18 units “in the morning” 14 units “in the evening”14 units “in the evening”  Previously Bed time NPH and daytime glipizide and metformin Bed time NPH and daytime glipizide and metformin Stopped because not good control and switched to aboveStopped because not good control and switched to above  Pt. refuses to take more than 2 shots a day

5. Other medications  ECASA 325 mg  Statin for cholesterol  CCB for blood pressure  ACE-I for blood pressure  BB for blood pressure  Diuretic for blood pressure  A1-blocker for BPH  OTC Acetaminophen as needed Acetaminophen as needed

6. 24 hour diet recall  Breakfast 7am – 10:30 AM Coffee, bowl of instant oatmeal, canned fruit Coffee, bowl of instant oatmeal, canned fruit  Lunch: only if breakfast before 8AM Can of soup, ½ gr cheese sandwich, diet soda Can of soup, ½ gr cheese sandwich, diet soda  Dinner: between 4:00 and 7:30 pm TV dinner: salsbury steak, mashed potatoes, green beans TV dinner: salsbury steak, mashed potatoes, green beans  Snacks: most often in evening, a candy bar or a sugar-free pudding with a cookie

7. Blood sugar record DateBBABBLALBDADBT Sun162134 Mon17584 Tue183 Wed35 Thu253164 Fri149 Sat16772 Sun206158 Mon152

8. Review of Systems  General: Feels fine, denies any complaints other than late day nervousness Feels fine, denies any complaints other than late day nervousness  Eyes: Last retinal exam 3 months ago, +mild-mod NPDR OU Last retinal exam 3 months ago, +mild-mod NPDR OU  CV: Denies CP, SOB, DOE, postural dizziness Denies CP, SOB, DOE, postural dizziness  Neuro: intermittent tingling and burning to both feet intermittent tingling and burning to both feet  GU: nocturia 1-2x nightly nocturia 1-2x nightly

9. Latest labs values (1 week ago) A1C: 8.5%A1C: 8.5% (range 7.5 – 8.7% for last 2 years) Fasting Glucose: 163 mg/dL Scr: 1.7 mg/dLScr: 1.7 mg/dL GFR: 45 mL/minGFR: 45 mL/min AST: 32 U/L ALT: 24 U/L Microalb/creatinine: 76.2 mg/g CRTMicroalb/creatinine: 76.2 mg/g CRT LDL-C: 66 mg/dL TG: 132 mg/dL

10. PE  Vitals: B/P: 124/62, HR: 98 reg B/P: 124/62, HR: 98 reg Ht: 67” Wt: 180 lbs BMI: 28 kg/m² Ht: 67” Wt: 180 lbs BMI: 28 kg/m²  General: Well-nourished, well-developed Well-nourished, well-developed African American man, A&Ox4, NAD African American man, A&Ox4, NAD

11. What are YOUR concerns? Hypoglycemia Hypoglycemia ElderlyElderly Long-standing DM with micro- and macrovascular complications:Long-standing DM with micro- and macrovascular complications: Retinopathy, nephropathy, neuropathy Retinopathy, nephropathy, neuropathy +Cardiac disease +Cardiac disease Lives ALONELives ALONE Very activeVery active Considerations: Considerations: Pt refuses > 2 “shots” a dayPt refuses > 2 “shots” a day Erratic sleep/wake scheduleErratic sleep/wake schedule Erratic meal timesErratic meal times Enjoys evening walkEnjoys evening walk

12. Mixed Insulin Replacement Therapy Time (hours) s.c. injection Normal Insulin Secretion at Meal Time Change in Serum insulin Analog Mix 75/25 Humalog Mix 70/30 Novolog Mix PreMix 70/30 (NPH/REG)

13. Treatment Strategies  Easier to change medications than to change habits  Analog Mix insulin can be dosed once, twice or three times a day  Available in Prefilled Pens  No need to time insulin far in advance of meal When food “in front of you” When food “in front of you” While eating While eating As late as 15 minutes after eating As late as 15 minutes after eating  Want him to continue to exercise!! What about dinner dose? What about dinner dose? Snack? Snack?  Appropriate A1C goal: Given his age, duration of DM, +complications, +Cardiac Hx Given his age, duration of DM, +complications, +Cardiac Hx ACCORD, ADVANCE, VADT ACCORD, ADVANCE, VADT  Pt. education: Treatment of hypoglycemia Treatment of hypoglycemia

14. Treatment of Hypoglycemia “Rule of 15”  Check BG when hypoglycemia is suspected (<70)  Treat with fast-acting source of carbohydrate: (15 grams)  4 glucose tabs, or 3 packets of sugar  1 cup (8 oz) SKIM milk  1/2 cup (4 oz) fruit juice or non-diet soda  8-10 fruit-flavored lifesavers or 3 peppermint stars  Wait 15 minutes!!!  Recheck blood sugar (must be >70)  Retreat if necessary. Activate EMS if BG <70 after 3 treatments  Teach significant others to use glucagon should pt become unconscious  Eat meal or snack: protein/CHO  Adjust treatment plan if frequent hypoglycemia

15. Preventing Hypoglycemic Emergencies  Test BG OFTEN >4 times daily, record, analyze >4 times daily, record, analyze  Test BG immediately when feeling hypoglycemic  Immediately and precisely treat hypoglycemia  Identify the earliest signs of hypoglycemia and pay attention to them  Test BG immediately before driving and do not drive if BG <110 Cognitive recovery 45-75 min after BG < 50 Cognitive recovery 45-75 min after BG < 50  Carry a rapidly absorbed glucose source  Wear a medical ID  Glucagon kit for emergencies