https://diabetes.acponline.org/archives/2017/02/10/4.htm

MKSAP quiz: Insulin pump management

This month's quiz asks readers to evaluate a 43-year-old man with multiple chronic complications from his diabetes, including end-stage kidney disease requiring hemodialysis, gastroparesis, frequent hypoglycemia with hypoglycemic unawareness, painful peripheral neuropathy, and proliferative retinopathy.


A 43-year-old man is evaluated during a follow-up visit for management of type 1 diabetes mellitus. He was diagnosed at 18 years of age and has multiple chronic complications from his diabetes, including end-stage kidney disease requiring hemodialysis, gastroparesis, frequent hypoglycemia with hypoglycemic unawareness, painful peripheral neuropathy, and proliferative retinopathy. The patient uses an insulin pump and a continuous glucose monitoring system to manage his diabetes. He is adherent with his regimen and performs multiple fingerstick blood glucose measurements with values ranging from 65 to 250 mg/dL (3.6-13.9 mmol/L). His most recent HbA1c level is 7.5%.

Which of the following is the most appropriate next step in the management of this patient?

A. Alter insulin pump settings to attain an HbA1c goal of less than 7.0%
B. Alter insulin pump settings to decrease the insulin doses
C. Discontinue the insulin pump, start subcutaneous insulin injections
D. Start gabapentin for treatment of painful peripheral neuropathy

Reveal the Answer

MKSAP Answer and Critique

The correct answer is B. Alter insulin pump settings to decrease the insulin doses. This item is available to MKSAP 17 subscribers as item 14 in the Endocrinology & Metabolism section. More information about MKSAP 17 is available online.

The most appropriate next step in management of this patient is to decrease the risk of hypoglycemia by decreasing the insulin doses delivered by the pump. This patient has had type 1 diabetes for 25 years with subsequent development of advanced microvascular disease. His frequent hypoglycemic events and hypoglycemic unawareness increase the risk of morbidity and mortality from recurrent hypoglycemia that may occur with stringent glycemic goals. Glycemic goals should be individualized to account for patient-specific factors, such as age and comorbidities. The American Diabetes Association suggests an HbA1c goal of less than 8.0% in patients with a decreased life expectancy, history of severe hypoglycemia, multiple comorbidities, or advanced microvascular or macrovascular disease. The less stringent HbA1c goal should be implemented to avoid recurrent hypoglycemia; however, the goal may need to be increased above 8.0% if it cannot be achieved safely.

Altering the pump settings to deliver more insulin to attain an HbA1c goal of less than 7.0% will increase his risk of hypoglycemia. His HbA1c goal should be liberalized to avoid hypoglycemia.

The risk of hypoglycemia can be reduced with lower insulin doses delivered by either an insulin pump or subcutaneous injections. Since the patient is already using an insulin pump, alteration of his insulin pump settings to deliver less insulin should occur next.

Gabapentin for treatment of his painful peripheral neuropathy is appropriate, but avoidance of recurrent hypoglycemia is the most serious issue that needs to be addressed next due to the associated increased risk of morbidity and mortality.

Key Point

  • A less stringent HbA1c goal is appropriate for persons with diabetes mellitus with a decreased life expectancy, history of severe hypoglycemia, multiple comorbidities, or advanced microvascular or macrovascular disease.