Project

1. TYPE 1 DIABETES MELLITUS
OSCAR KWAN
PHARM.D CANDIDATE 2018
ST. JOHN’S UNIVERSITY
OSCAR.KWAN11@STJOHNS.EDU

2. PATIENT CASE
Age: 24 years old
Sex: Female
Ethnicity: Spanish
PMHx: Pre-HTN, MDD, Anxiety, Obesity, Scoliosis, EtOH abuse, and mild Anemia
Findings: Glucose reading of 520 mg/dl on 1/16/18 with weight loss ~14 lbs over one month
CC: Polydipsia, Polyuria, Loss of appetite, Sharp chest pains/palpitations at rest
FH: Type II DM (father)
SH: Social drinker for 2 -3 years, had experienced withdrawal symptoms before
Former smoker

3. MEDICATION LIST
1) Mirtazapine 15 mg: 1 tab PO once a day for Depression
2) Folic Acid 1 mg: 1 tab PO once a day for EtOH history
3) Multiple Vitamins: 1 tab PO once a day for EtOH history
4) Thiamine 100 mg: 1 tab PO once a day for EtOH history

4. VITALS
(1/23/18)
Temp 36.7 C
HR 102 bpm
RR 20 bpm
BP 149/90 mmHg
Weight 114.3 kg
IBW 58.2 kg
AdjBW 80.64 kg
Height 166.5 cm
BMI 41.1 kg/m2(OBESE)
CrCl 149 ml/min
eGFR >60 ml/min

5. LABS
Basic Metabolic Panel (1/16/18)
Sodium 135 mEq/L
Potassium 5.1 mEq/L
Chloride 95 mEq/L
CO2 26 mEq/L
BUN 9 mg/dl
Creatinine 0.87 mg/dl
Glucose 520 mg/dl
AGAP 14
Calcium 9.7 mg/dl
(1/17/18)
Glucose Whole Blood Meter POC: 350 mg/dl

6. LABS
HgbA1c
10.4% (1/16/18)
10.2% (1/12/18)
4.7% (9/6/16)
4.3% (4/18/13)
Hepatic Function Panel (1/16/18)
AST 129 U/L
ALT 145 U/L

7. ASSESSMENT
• Patient was diagnosed with Type II DM due to meeting criteria and family history.

8. PLAN
1) Acutely manage patient’s hyperglycemia with insulin at a recommended dose of 0.1 units/kg
2) Prescribed patient Lantus 10 U QHS
3) Counseled patient on how to use lancets and glucometer 3x day (Before breakfast, 2 hours
after lunch, and 2 hours after dinner)
4) Educated patient about reducing carbohydrate load (juice/rice) and exercise

9. EXERCISE

10. GOALS AND MONITORING
1) Reassess HgA1c in 3 months with goal of <= 7%
2) Monitor for signs of hypoglycemia ((shakiness, irritability, confusion, tachycardia, hunger)

11. GOALS AND MONITORING
3) Reassess mental health

12. FOLLOW-UP
• On 1/19/18, her glucose level improved in 1 day of insulin and decreased to 184 mg/dl
• On 1/24/18, she was phone called for updated glucose readings (Range: 96 – 280 mg/dl)
1/24 @ 11 am: 124 mg/dl (Fasting)
1/23 @ 8 pm: 96 mg/dl (Fasting)
@ 11 pm: 146 mg/dl (Post-Prandial)
1/22 @ 1 pm: 167 mg/dl (Fasting)
@ 4 pm: 127 mg/dl (Post-Prandial)
@11 pm: 154 mg/dl
1/21 @ 2 pm: 115 mg/dl
@7 pm: 127 mg/dl
@ 9 pm: 231 mg/dl
1/20 @1 pm: 258 mg/dl
@ 6 pm: 264 mg/dl
@ 10 pm: 280 mg/dl Had consumed EtOH due to sister visit
1/19 @ 11 am: 185 mg/dl
@ 5 pm: 152 mg/dl
@ 9 pm: 255 mg/dl

13. FOLLOW-UP
• On 1/23, patient reported headaches/migraines, shakiness at night, fatigue, difficulty
concentrating, nausea, and heart palpitations. New labs were ordered.

14. LABS
Urinalysis POC (1/23/18)
U Bilirubin POC 1+ [ Negative ]
U Blood POC Negative [ Negative ]
U Glucose POC Negative [ Negative ]
U Ketones POC 2+ [ Negative ]
U Leuk Est POC 1+ [ Negative ]
U Nitrates POC Negative [ Negative ]
U Protein POC 1+ [ Negative ]
UA Appear POC Slightly Cloudy [ Clear ]
UA Color POC Other
U Spec Grav POC 1.015 [ 1.005-1.030 ]
UA URO POC 0.2 [ 0.2-1.0 mg/dL ]
U pH POC 5.5 [ 5.0-8.0 ]

15. LABS
Blood Ketones Test [1/23/18]
Beta Hydroxybutyric Acid 0.5 [<= 0.27 mmol/L]
This quantitative Beta-Hydroxybutyrate (BHB) assay replaces the previously
used Beta-Hydroxybutyrate and Ketone assays. Ordinarily, Beta-Hydroxybutyrate
is the ketoacid present in the highest amount in serum. During periods of
ketosis, Beta-Hydroxybutyrate increases more than the other two ketoacids,
acetoacetate and acetone, and has been shown to be a better index of
ketoacidosis, including the detection of subclinical ketosis.
Beta-Hydroxybutyrate measurement is therefore the preferred method to
determine the presence and degree of ketosis.

16. LABS
Basic Metabolic Panel (1/23/18)
Sodium 139 mEq/L
Potassium 3.9 mEq/L
Chloride 101 mEq/L
CO2 22 mEq/L
BUN 6 mg/dl
Creatinine 0.74 mg/dl
Glucose 98 mg/dl
AGAP 16
Calcium 9.1 mg/dl
(1/23/18)
Glucose Whole Blood Meter POC: 118 mg/dl (65 - 95 mg/dl)

17. LABS
Blood Gas Venous (1/23/18)
PH Venous 7.37 [7.35 – 7.41]
PCO2 Venous 48 [40-45 mmHg]
PO2 Venous 21 [30-49 mmHg]
BE Venous 2.5 [-2.0 – 3.0 mmol/L]
SO2 Venous 27.2 [55 - 71%]
HCO3 Venous 24 [21-28 mmol/L]
Patient Temp Ven 37.0 [Celsius]
PH Corrected Ven 7.37 [7.36 – 7.41]
PCO2 Corrected Ven 48 [40-45 mmHg]
PO2 Corrected Ven 21 [30-49]
(1/23/18)
Glucose Whole Blood Meter POC: 118 mg/dl (65 - 95 mg/dl)

18. LABS
[1/23/18]
Glutamic Acid Decarboxylase (GAD 65) Auto Antibodies >120 [<5 U/ml = NEGATIVE]
GAD is a neuronal enzyme involved in the synthesis of the neurotransmitter GABA. Antibodies directed
against the 65-kd isoform of GAD (GAD65) are seen in a variety of autoimmune neurologic disorders.
GAD65 antibody is also the major pancreatic islet antibody and an important serological marker of
predisposition to type 1 diabetes.

19. ASSESSMENT
• Urine Dip test showed trace glucose and ketones
• Venous Blood Glucose (VBG) was non-acidodic, CBC was WNL
• Patient’s ketotic blood and urine were secondary to ketogenic diet that was unrevealed to PMD
• S.N. is diagnosed with Type 1 DM, specifically Immune-mediated diabetes
• Autoimmune markers of DMI include antibodies to GAD65, Insulin, Tyrosine Phosphatases IA-2
and IA-2B, and ZnT8
• Type 1 diabetes defined by the presence of one or more of these autoimmune markers
• Type 1 diabetes has strong HLA associations, with linkage to the DQA and DQB genes.

20. KETOGENIC DIET

21. TREATMENT
• Insulin is the mainstay of therapy for individuals with type 1 diabetes.
• Generally, the starting insulin dose is based on weight, with doses ranging from 0.4 to 1.0 units/kg/day of total insulin
• The American Diabetes Association/JDRF Type 1 Diabetes Source book notes 0.5 units/kg/day as a typical starting
dose in patients who are metabolically stable, with higher weight-based dosing required immediately following
presentation with ketoacidosis

22. PRAMLINTIDE
• FDA-approved for use in adults with type 1 diabetes
• Amylin analog
• Delays gastric emptying, blunts pancreatic secretion of glucagon, and enhances satiety
• Induce weight loss and lower insulin doses

23. INVESTIGATIONAL AGENTS
1. Metformin:
• Adjunct therapy may reduce insulin requirements and improve metabolic control in
overweight/obese patients with poorly controlled type 1 Diabetes
• Not FDA-approved for use in patients with type 1 DM
2. Incretin-Based Therapies
• GLP-1 agonists (NOT FDA-approved for type 1 DM)
• DPP-4 inhibitors (NOT FDA-approved for type 1 DM)
3. Sodium-Glucose Cotransporter 2 Inhibitors
• NOT FDA-approved for type 1 DM
• Insulin-independent glucose lowering by blocking glucose reabsorption at proximal
renal tubule by inhibiting SGLT2

24. STAGING OF TYPE 1 DM
S.M.

25. THE 500 RULE
• An estimation of many grams of carbohydrate one unit of Humalog or Novolog insulin covers
• 500 divided by your TDD (total daily dose of insulin) = Carb Ratio
• Most accurate for type 1 Diabetes because there is no innate insulin production
• To find out how many units of insulin is needed to cover a meal, divide the grams of carb
consumed by your carb ratio.
Example) S.M.’s TDD = 50 units
Carb Ratio = 500/TDD = 500/50 = 10 grams of carb covered by each unit of Humalog
Grams of Carb consumed = 600 grams
Units of Insulin needed = (600 g)/(10 g/U) = 60 Units of insulin needed for 600 g carbs

26. INSULIN SENSITIVITY FACTOR
• Used to determine the drop in blood glucose level (mg/dl) per unit of SA-insulin
• Useful for type 1 Diabetic patients only
• Insulin Sensitivity Factor = 1,800/TDD
Example) Someone’s TDD = 40 units
Insulin Sensitivity Factor = 1800/40 units = 45 mg/dl of blood sugar is lowered by 1 unit
of SA-insulin