Question

Marie, age 50, has type 1 diabetes and checks her blood glucose level several times every day. Her blood glucose level ranges from 250 to 280 mg/dL in the morning and is usually about 140 at lunch, about 120 at dinner, and about 100 at bedtime. In the morning, she takes 30 units of neutral protamine Hagedorn (NPH) insulin and 4 units of regular insulin, and before dinner she takes 18 units of NPH insulin and 4 units of regular insulin. Although she has had her insulin dose adjusted several times in the past month, it has had no effect on her high morning blood glucose level. What is your next course of action?

1) Increase the evening NPH insulin dose by 2 more units.
2) Have her check her blood glucose level between 2 am and 4 am for the next several days.
3) Increase the morning regular insulin dose by 2 units.
4) Order a fasting blood sugar test.

Answer 1

The next step for Marie, who has type 1 diabetes and consistently high morning blood glucose levels, is to monitor her blood glucose levels between 2 am and 4 am to check for nocturnal hypoglycemia or inadequate overnight insulin coverage.

Step-by-step explanation:

Given the clinical scenario described involving Marie, a 50-year-old with type 1 diabetes, the appropriate next course of action would be to monitor her nocturnal blood glucose levels. Thus, the correct choice from the provided options is to have her check her blood glucose level between 2 am and 4 am for the next several days (option 2). This step will help determine if she experiences the Somogyi effect, where nocturnal hypoglycemia leads to a counterregulatory rebound hyperglycemia in the morning, or if she has insufficient insulin coverage overnight that causes high morning blood glucose levels.

Marie's morning blood glucose readings consistently exceed the desired fasting blood glucose range of 70-130 mg/dL, indicating that adjustments to her insulin regimen may be necessary. However, before modifying her insulin dosage, it's crucial to understand the underlying cause of her high morning blood glucose readings. Further intervention and insulin adjustments should be guided by additional blood glucose monitoring as well as consultation with her healthcare provider specializing in diabetes management.