CASE SIMULATIONS
2023
CASE 1:
A CASE OF SOMOGYI EFFECT
Mrs. WP is a 45-year-old lady who was referred to DMTAC today to rule out the issue of nonadherence to insulin. She was diagnosed with T2DM 2 years ago and upon discharge, was
given SC Actrapid® 10 IU TDS and SC Insulatard® 20 IU ON. However, after several visits to
the clinic, her SC Insulatard® dose was slowly increased to 40 IU ON due to her uncontrolled
FPG. Upon further interviewing, Mrs. WP claimed she sometimes experienced occasional
unusual sweating and nightmares at night for the past 2 weeks. She also woke up feeling
lethargic and having headaches.
DMTAC Visit
Medical history
1
T2DM for 2 years
Body Weight
80.0 kg
Height
150 cm
Blood Pressure
Current
medications
150/90 mmHg
SC Actrapid® 10 IU TDS
SC Insulatard® 40 IU ON
T. Metformin 1 g BD
T. Perindopril 4 mg OD
T. Simvastatin 20 mg ON
Laboratory
parameters
FPG
: 14.1 mmol/L
HbA1c
: 8.1 %
SCr
: 89 µmol/L
T. Cho
: 4.3 mmol/L
LDL
: 2.2 mmol/L
HDL
: 1.2 mmol/L
TG
: 2.1 mmol/L
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Questions :
1.
Mrs. WP claimed that she has not been doing SMBG regularly since her strips finished and
her readings are always “high”. How would you advise Mrs. WP about SMBG and how
would you suggest the timing and frequency of SMBG?
● SMBG is important to evaluate patients’ responses to their insulin therapy to assess if they
achieve their glycaemic targets, to fine-tune their insulin dose regimen through
adjustment of insulin doses as well as help to identify hypoglycaemia1.
● These should be explained to Mrs. WP so that she is aware of how SMBG helps to improve
her glycaemic profile and also to minimize her hypoglycaemic episodes.
● Since she is on a basal-bolus insulin regimen, it is recommended that she does a 4-point
SMBG profile, i.e. FPG / pre-meal / pre-bed BG.
● In view of her symptoms (sweating, nightmares, lethargy and headache), it is
recommended that she check her BG around 2.00 – 3.00 am to determine if there are any
occurrences of nocturnal hypoglycaemia.
2.
Mrs. WP started doing regular SMBG and these are her SMBG readings. Based on her
readings, how would you manage her situation?
SMBG (mmol/L)
Day / Time
Pre-breakfast
Pre-lunch
Pre-dinner
Pre-bedtime
2.00 – 3.00
am
01/05/2023
14.5
6.9
8.0
6.8
3.5
05/05/2023
15.1
7.2
8.2
7.0
4.1
07/05/2023
14.8
7.1
8.3
7.1
3.5
11/05/2023
14.0
6.6
8.0
7.2
3.8
● Her readings showed Somogyi effect, i.e. nocturnal hypoglycemia and rebound
hyperglycaemia the next morning.
● Therefore, we need to reduce her basal dose to avoid nocturnal hypoglycaemia.
2|C ase sim ul at i ons 20 23
3.
How do we differentiate between Somogyi Effect and Dawn Phenomenon?
Comparison
Somogyi Effect
Dawn Phenomenon
High FPG
Yes. Morning hyperglycaemia is Yes. Morning hyperglycaemia can
due to treatment with excessive be recurring.
amounts of exogenous insulin2.
Nocturnal
hypoglycaemia
Yes
Cause
-
-
-
-
No
Excessive basal insulin dose
causing
nocturnal
hypoglycemia.
When BG drops, there is an
activation
of
counterregulatory hormones such as
adrenaline, corticosteroids,
growth
hormone,
and
glucagon3.
This activates glycogenolysis,
glyconeogenesis,
gluconeogenesis, stimulating
the liver to produce glucose3.
Hence, there is a rise in early
morning BG.
- Physiologic
decrease
of
endogenous insulin secretion
between 3.00 – 5.00 am and
the reducing effect of the
exogenous
basal
insulin
administered to the patient the
day before.
- Both of these events unblock
the secretion of insulinantagonistic
hormones
secretion,
mainly
growth
hormones,
cortisol
and
catecholamines which signal
the liver to boost the
production of glucose2
- Because of the impaired
function of pancreas beta cells
in T2DM patients, there is
insufficient insulin secretion in
response
to
this
2
hyperglycaemia , leading to an
overall increase in circulating
BG during dawn.
Diagnosis
Hypoglycemia readings around Normal / High BG levels around
2.00 am to 3.00 am which increase 2.00 am to 3.00 am, increasing to
to hyperglycaemia in the morning morning hyperglycaemia
3|C ase sim ul at i ons 20 23
Prevention/
Management
Reduce pre-bed basal / pre-dinner Increase pre-bed basal / pre-dinner
premixed insulin dose. Long-acting premixed insulin dose.
analogue
insulin
may
be
considered.
Learning points:
•
•
DO NOT simply increase insulin dose when you see high FPG.
A BG level at 2.00 am – 3.00 am by SMBG or CGM is the best way to distinguish
both phenomena2.
References:
1. Ministry of Health; Malaysia (2011) "Practical Guide to Insulin Therapy in Type 2
Diabetes Mellitus (1st Edition)."
2. Rybicka, M., Krysiak, R., Okopień, B. (2011). “The dawn phenomenon and the Somogyi
effect - two phenomena of morning hyperglycaemia”. Endokrynol Polska, 62(3): 276-84.
3. Reyhanoglu, G., Rehman, A. (2023). “Somogyi Phenomenon”. StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing.
4|C ase sim ul at i ons 20 23
CASE 2:
A CASE OF INSULIN INTENSIFICATION
(PREMIXED INSULIN VERSUS BASAL-BOLUS REGIMEN)
Mr. NA, 59 years old, retired gentleman. He was diagnosed with T2DM in 2012 and has had
regular follow-ups at a government health clinic. His diabetes was managed with Mixtard® and
Metformin.
DMTAC Visit
Medical history
1
T2DM for 2 years
Body Weight
76.0 kg
Height
165 cm
Blood Pressure
Current medications
Laboratory parameters
MYMAAT and DFIT
Diet and lifestyle
120/83 mmHg
SC Mixtard® 46 IU BD
T. Metformin 1 g BD
T. Amlodipine 5 mg OD
T. Perindopril 4 mg OD
T. Cardiprin® 100 mg OD
T. Simvastatin 20 mg ON
FPG
: 15.4 mmol/L
HbA1c
: 10.7 %
LDL
: 0.8 mmol/L
HDL
: 0.9 mmol/L
TG
: 2.6 mmol/L
SCr
: 79 µmol/L
eGFR (CKD-EPI)
: 99 ml/min
UACR
: < 30 mg/g
60/60 and 100%
- Breakfast, lunch and dinner is usually around 8.30 am 1.00 pm
and 8.30 pm respectively
- Very seldom exercise due to knee pain
5|C ase sim ul at i ons 20 23
Date
28/8/2014
27/3/2016
19/3/2017
19/11/2017
11/2/2018
28/4/2019
7/6/2020
5/9/2021
HbA1c
7.2 %
6.2 %
8.7 %
-
10.2 %
10.7 %
10.0 %
10.7 %
8.6
7.6
7.2
9.1
13.9
10.0
14.1
15.4
78.4 kg
80.0 kg
80.0 kg
79.0 kg
79.0 kg
78.0 kg
78.0 kg
77.0 kg
Dose of
Insulin/
OGLDs
Glucovance®
(500/5) II/II
BD
Glucovance®
(500/5) II/II
BD and
Insulatard®
12 IU ON
Glucovance®
(500/5) II/II
BD and
Insulatard®
12 IU ON
Glucovance®
(500/5) II/II
BD and
Insulatard®
14 IU ON
Metformin
1g BD and
Mixtard® 32
IU BD
Metformin
1g BD and
Mixtard®
40 IU BD
Metformin
1g BD and
Mixtard®
44 IU BD
Plan
Started with
Insulatard®
6 IU ON
Continued
with the
same
regimen
Continued
with the
same
regimen
Increase the
dose of
Insulatard®
to 16 IU ON
Glucovance®
(500/5) II/II
BD and
Insulatard®
16 IU ON
Change
insulatard®
16 IU ON to
Mixtard® 20
IU BD
Increase the
dose of
Mixtard® to
34 IU BD
Increase
the dose of
Mixtard®
to 42 IU
BD
Increase
the dose of
Mixtard®
to 46 IU
BD
FPG
(mmol/L)
Body
weight
Questions :
1.
Based on Mr. NA’s glycaemic control over the past few years (2014 to 2021), what are
your opinions/comments on his T2DM management, particularly the insulin regimen?
● Mr. NA’s HbA1c and FPG were once well-controlled with dual OGLDs and basal insulin
(Insulatard®) in 2016 with a HbA1c reading of 6.2 %. However, this condition was only
maintained for almost a year before it became poorly controlled again in 2017.
● Although the basal-bolus insulin regimen is considered by many as "the golden standard"
in reaching the glycaemic target, proper use of intensified insulin regimens, such as
premixed or basal-bolus insulin regimen, will result in similar HbA1c reduction,
hypoglycaemic events, and weight gain1.
● In view of Mr. NA’s fixed meal plan and own preference (favor fewer injections), his insulin
regimen was switched from basal insulin to premixed insulin (Mixtard®) in 2018. However,
optimization of the dose of Mixtard® from 20 IU BD to 46 IU BD did not improve the HbA1c
readings from 2018 to 2021.
2.
Mr. NA found a new job as a sales representative. His mealtimes became irregular due
to his busy schedule. Upon assessment, Mr. NA showed good medication adherence &
satisfactory injection technique. How would you adjust the insulin regimen to reduce
Mr. NA HbA1c to his target HbA1c < 6.5 %, FPG < 7.0 mmol/L and 2HPP < 8.5 mmol/L?
6|C ase sim ul at i ons 20 23
● Mr. NA’s insulin regimen was intensified from premixed insulin (Mixtard®) to basal-bolus
insulin regimen (Actrapid® + Insulatard®) due to his irregular mealtimes. His Metformin
and the rest of the medications continued.
● During the intensification from a premixed insulin regimen to a basal-bolus insulin
regimen, the dose of bolus (Actrapid®) and basal (Insulatard®) insulin were calculated by
transferring the total premixed insulin dose first, followed by splitting the total dose in a
ratio of 50:50 2. In this case, the dose of basal insulin (Insulatard®) was reduced by 20 %,
from the calculated 46 IU to 36 IU ON, to avoid nocturnal hypoglycaemia.
● Mr. NA was started with Actrapid® 16 IU TDS and Insulatard® 36 IU ON.
After 6 visits to the DMTAC service, from October 2021 to August 2022, with a number of
interventions (including insulin injection technique, emphasis on SMBG and insulin dose
adjustments), as well as the regular doctor’s checkup, referral to dietician and
physiotherapist, Mr. NA’s HbA1c was successfully reduced from 10.7 % to 8.6 % in August
2022.
Learning points:
•
•
With an increasing number of treatment options available, T2DM management is
moving away from a “one-size-fits-all” approach and towards patient-centered
communication and shared decision-making1.
Although a basal-bolus insulin regimen mimics the physiologic action of
endogenous insulin secretion, insulin regimen should be individualized based on
patient’s needs (i.e. lifestyle, concerns)2. DO NOT simply increase insulin dose
when you see high FPG.
References
1. Miyoshi, H., Baxter, M., Kimura, T., Hattori, M., Morimoto, Y., Marinkovich, D., Tamiwa,
M., Hirose, T. (2021). “A Real-World, Observational Study of the Initiation, Use, and
Effectiveness of Basal-Bolus or Premixed Insulin in Japanese People with Type 2
Diabetes”. Diabetes Therapy, 12:1341-57.
2. Ministry of Health; Malaysia (2020) "Clinical Practice Guidelines: Management of Type 2
Diabetes Mellitus (6th Edition)."
7|C ase sim ul at i ons 20 23
CASE 3:
A CASE OF UNCONTROLLED DM ON HIGH INSULIN DOSE
Mr. SA is a 40 years old gentleman, with T2DM for 3 years under health clinic follow up. He is
married and blessed with 2 children and currently working as an accountant.
DMTAC Visit
1
Medical history T2DM for 3 years
Body Weight
80.0 kg
Height
175 cm
Blood Pressure
Current
medications
123/80 mmHg
SC Insugen R® 30 IU TDS
SC Insugen N® 50 IU ON
T. Metformin 1 g BD
T. Vildagliptin 50 mg BD
T. Simvastatin 40 mg ON
Laboratory
parameters
FPG
: 12.5 mmol/L
HbA1c
: 10.1 %
MyMAAT
50/60
DFIT
95 %
Diet and
lifestyle
- Breakfast (8 am) : “nasi lemak tiga segi” 1 packet / ”bihun sup” /
sandwich, plain water
- Morning tea (10.30 am) : bread 2 pieces/biscuit 4-5 pieces, 2-in-1 coffee
- Lunch (1 pm) : rice 2-3 scoops, fish /chicken/beef with gravy, minimal
vegetable, plain water
- Tea time (4pm) : “kuih” / ”pisang goreng” 3-4 pieces, teh-O
- Dinner (8pm) : same as lunch / nasi goreng / kuey teow goreng, plain
water
- Supper (10-11 pm) : if hungry will eat crackers 2-3 pieces / a glass of milk
(3-4 times/week)
- No exercise
8|C ase sim ul at i ons 20 23
Further
information
Date
12/3/23
16/3/23
20/3/23
- Injection technique is fair, sometimes forget to re-suspend basal insulin
before injection. No lipodystrophy.
- Normally injects pre-dinner insulin at 7.00 pm but eats around 8.00 pm.
- Claims moderately compliant with insulin injection.
- Admits to gaining weight of 6 kg for the past 3 months.
- Complains of frequent hunger pangs in between meals, hence will snack
whenever hungry.
- Sometimes will wake up in the middle of the night with nightmares or is
covered in damp clothes but he thought it was not related to
hypoglycaemia and therefore, he does not check his SMBG.
SMBG (mmol/L)
Pre-breakfast (7.30 am)
Pre-lunch (12.30 pm)
11.3
12.7
10.9
13.0
11.6
12.5
Pre-dinner (7.00 pm)
14.5
13.8
13.5
Questions :
1.
What is your comment on Mr. SA’s glycaemic control?
● Uncontrolled DM with HbA1c 10.1 % and all pre-meal SMBG are above target despite on
high-dose insulin [TDD = 140 IU (1.75 IU/kg/day)].
● His target HbA1c should be < 6.5 % as he is young and has no other complications.
2.
What are the possible causes of Mr. SA's uncontrolled diabetes?
● Mr. SA might be having hypoglycaemia, as he experienced excessive hunger, nightmares
and drenching night sweats.
● The recurrent hypoglycaemia led to frequent snacking in between meals which
contributed to high pre-lunch and pre-dinner BG as well as weight gain.
● Incorrect insulin injection timing at dinner:
o His dinner was one hour after injecting prandial insulin. This will increase the risk of
hypoglycaemia and subsequently render the insulin action to be less effective.
● Inappropriate injection technique:
o Failure to mix cloudy insulin before injection can alter the insulin concentration,
causing variable clinical responses and associated with higher insulin consumption1.
9|C ase sim ul at i ons 20 23
3.
Comment on Mr. SA’s insulin regimen. How will you manage this patient?
● Mr. SA’s insulin dose was too high with a TDD of 1.75 IU/kg/day resulting in frequent
hypoglycaemia. The insulin dose should be reduced and titrated according to his SMBG.
● Estimating new insulin requirement for Mr. SA ≈ 1 IU/kg/day (Optimal TDD of 0.5 - 1.0
IU/kg/day in most patients)
Calculations:
1 IU/kg/day x 80 kg = 80 IU/day
● Following the determination of TDD requirement, the proportion of basal to prandial
insulin requirement may be estimated using a ratio of 50:50. The basal dose is usually
administered at bedtime (conventional insulin) and the prandial portion is divided into
three to cover the three main meals. Estimation of the pre-meal dose should take into
consideration the size of the meal, in terms of the carbohydrate content.
Calculations:
TDD 80 IU/day is divided into a ratio of 50:50 (i.e. 40 IU basal and 40 IU prandial insulin)
• Therefore, Mr. SA’s new insulin regimen can be SC Insugen R® 14 IU TDS and SC Insugen
N® 40 IU ON. Subsequently, insulin should be titrated accordingly towards attaining his
individualized glycaemic target while minimizing hypoglycaemia. In addition, Mr. SA
should also be counselled on lifestyle modifications such as diet and exercise.
10 | C a s e s i m u l a t i o n s 2 0 2 3
Learning points:
•
Insulin dose shall not be increased abruptly following high SMBG readings.
Investigation of the followings shall be done before adjusting the insulin doses:
- Hypoglycaemia
- Medication adherence
- Injection technique
- Administration timing (conventional insulin/analogue)
- Frequency of needle change
- Rotation of injection sites
- Lipodystrophy
- Insulin storage
- Faulty glucometer or expired glucose strips
- Other medications that might contribute to hyperglycaemia e.g. Steroid or
traditional medicines
- Infections
• Optimal TDD of 0.5 - 1.0 IU/kg/day in most patients. The recalculation of TDD of 1
IU/kg/day in this case is only served as a guide. Patient’s willingness and motivation
to change lifestyle should also be assessed. The importance and benefit of healthy
food choice and increase physical activity should be emphasized in the counselling.
If patient willing to change the diet, a lower starting dose at 0.7 IU/kg/day and then
titrate up if inadequate. Patient with insulin resistance or obese may require more
than 1.0 IU/kg/day.
• The TDD of insulin shall be individualized and take into consideration of several
factors (eg. Patient’s BMI, dietary habits, glycaemic target, glycaemic control,
insulin resistance, compliance, hypoglycaemia risk, etc).
References
1. Frid, A.H., Kreugel, G., Grassi, G., Halimi, S., Hicks, D., Hirsch, L.J., Smith, M.J.,
Wellhoener, R., Bode, B.W., Hirsch, I.B., Kalra, S., Ji, L., Strauss, K.W. (2016). “New
Insulin Delivery Recommendations”. Mayo Clinic Proceedings, 91(9):1231-55.
2. Ministry of Health; Malaysia (2011) "Practical Guide to Insulin Therapy in Type 2
Diabetes Mellitus (1st Edition)."
11 | C a s e s i m u l a t i o n s 2 0 2 3
CASE 4:
A CASE OF INAPPROPRIATE INSULIN REGIMEN
Mr ABC, 45 years old, T2DM for 9 years under health clinic follow up. He works as a sales
person, claims moderately compliant to insulin injection (missed injection 3 times per month).
DMTAC Visit
Medical history
1
T2DM for 9 years
Body Weight
57.0 kg
Height
165 cm
Blood Pressure
Current
medications
150/90 mmHg
SC Mixtard® 38 IU BD
T. Metformin 1 g BD
T. Vildagliptin 50 mg BD
Laboratory
parameters
Day
1
2
3
FPG
:
8.9 mmol/L
HbA1c
: 9.8 %
SMBG (mmol/L)
Pre-breakfast
Pre-lunch
8.5
5.8
7.9
6.1
8.3
5.6
Pre-dinner
15.9
17.4
13.8
After reviewing his SMBG records, SC Mixtard® 38/10/38 TDS was prescribed.
12 | C a s e s i m u l a t i o n s 2 0 2 3
Questions :
1.
What is your opinion on Mixtard® TDS regimen ?
● Not recommended
● Premixed human insulin consists of short-acting human insulin and intermediate-acting
insulin
● Insulin stacking happens when premixed human insulin is given three times a day
● Increases the risk of hypoglycaemia
2.
If the patient agreed on three injections a day, what are the options available and their
rationale?
Options
i) Premixed human
insulin BD + prandial
insulin at pre-lunch
-
ii) Premixed analogue
TDS
-
Rationales
Better option if premixed insulin analogue is not readily
available
Less insulin stacking compared to premixed human
insulin TDS
Add prandial insulin 6 IU or 10 % total daily dose at
lunch
Titrate dose once or twice a week to achieve the next
pre-prandial goal of < 7.0 mmol/L
Best option if it is available, provided cost is not an issue
Less insulin stacking for premixed insulin analogue TDS
Premixed insulin analogue minimizes hypoglycaemia in
between meals
Single pen for three times injection
Greater flexibility as it can be injected prior to, during,
or immediately after a meal
13 | C a s e s i m u l a t i o n s 2 0 2 3
Learning points:
•
•
The choice of insulin regimen should be individualized, based on the patient’s
glycaemic profile, dietary pattern, lifestyle and acceptability1.
Mixtard TDS regimen is not recommended as it increases the risk of
hypoglycaemia due to insulin stacking1.
References
1. Ministry of Health; Malaysia (2020) "Clinical Practice Guidelines: Management of Type 2
Diabetes Mellitus (6th Edition)."
2. Ministry of Health; Malaysia (2011) "Practical Guide to Insulin Therapy in Type 2
Diabetes Mellitus (1st Edition)."
14 | C a s e s i m u l a t i o n s 2 0 2 3
CASE 5:
A CASE OF INSULIN INTENSIFICATION (SWITCHING FROM
CONVENTIONAL TO INSULIN ANALOGUE)
Mr. APL is a 55 years old gentleman, who works as a security guard at a housing area. He was
referred to DMTAC by the doctor in view of uncontrolled diabetes and compliance issues.
DMTAC Visit
Medical history
1
T2DM, Hypertension, Dyslipidemia
Body Weight
80.0 kg
Height
172 cm
Blood Pressure
Current
medications
134/77 mmHg
T. Metformin 1 g BD
SC Insugen R® 24 IU TDS
SC Insugen N® 24 IU ON
T. Losartan 100 mg OD
T. Atorvastatin 20 mg ON
Laboratory
parameters
FPG
: 13.5 mmol/L
HbA1c
: 14.1 %
MyMAAT
32/60
DFIT
90 %
Diet and lifestyle
Morning shift (7.00 am-7.00
Night shift (7.00 pm-7.00 am)
pm):
- 10.00 am: nasi lemak / roti
canai, teh-O
- 8.00 pm: rice, vegetables,
fish/chicken curry, plain
water
- 11.00 pm: bed
15 | C a s e s i m u l a t i o n s 2 0 2 3
- 8.00 am: nasi lemak / roti
canai, teh-O
- 10.00 am: sleep
- 5.00 pm: rice, vegetables,
fish/chicken curry, plain
water
- 12.00 - 1.00 am: on and off
he needs to take snacks,
especially after basal insulin
Further
information
- Claims to inject prandial insulin twice a day because he
usually has two main meals only
- He eats immediately after injecting Insugen R® as he needs
to rush for errands
- He skips basal insulin whenever he works the night shift as
he frequently experiences hypoglycaemia during the night
shift
- Claims compliant with oral medications.
- No SMBG, he cannot afford a glucometer.
- Injection technique is fair. No lipodystrophy.
Questions:
1.
What are the main reasons that cause uncontrolled diabetes in Mr. APL?
● Poor adherence to basal insulin (MyMAAT score 32/60)
● Wrong injection time of short-acting insulin. The mismatch between insulin and meal
time could render the insulin action to be less effective.
2.
How would you adjust Mr. APL’s insulin regimen to suit his lifestyle and work nature?
Option 1: Basal Plus Analogue Regimen
● Prandial insulin is preferred as this patient was unable to inject 30 minutes before his
meal.
● As he frequently experiences hypoglycaemia during the night shift, a basal insulin
analogue with peakless action and a lesser risk of hypoglycaemia will be a better
choice for him. Furthermore, he can inject basal insulin analogue at any time of the
day (as long as same timing every day).
● Therefore, the patient was suggested for SC prandial insulin analogue twice daily at
main meals and SC basal insulin analogue once daily.
16 | C a s e s i m u l a t i o n s 2 0 2 3
Option 2: Premixed Analogue BD Regimen
● Premixed analogue BD may be considered if the patient preferred fewer injections
(provided patient has consistent mealtimes).
Learning points:
•
•
•
•
Insulin analogue provides flexibility for patients with lifestyle restriction, i.e. the
need to eat immediately due to job schedule, variable carbohydrate intake, etc.
Premixed insulin analogue meets the needs of patients who require both basal
and prandial insulin but wish to limit the number of daily injections.
Insulin analogue has lower risk of hypoglycaemia.
When starting patients on insulin analogues, cost and availability need to be
considered.
References:
1. Ministry of Health; Malaysia (2011) "Practical Guide to Insulin Therapy in Type 2
Diabetes Mellitus (1st Edition)."
17 | C a s e s i m u l a t i o n s 2 0 2 3
CASE 6:
A CASE OF INSULIN DE-ESCALATION
Mrs. A, a 34-year-old female, is a single mother of 2 children. She works from home as a baker
and is always busy baking.
She was diagnosed with DM after her first childbirth 4 years ago. She has a strong family history
of T2DM (both parents and 1 elder brother). She delivered a second child 2 years ago and since
then has been on SC Mixtard®.
She has completed her family and not breastfeeding. She was referred to DMTAC for
hypoglycemia despite HbA1c of 8.7%
DMTAC Visit
Medical history
1
T2DM for 4 years
Body Weight
69.0 kg
Height
160 cm
Current medications
SC Mixtard® 34/20 IU BD
T. Metformin 1 g BD
Laboratory
parameters
FPG
:
9.0 mmol/L
HbA1c
:
8.7 %
eGFR
:
> 90 ml/min
MyMAAT
32/60
DFIT
100 %
18 | C a s e s i m u l a t i o n s 2 0 2 3
Further information
- She claims to have frequent hypoglycaemia, but no obvious
pattern.
- Misses morning insulin dose on and off as busy with children and
work.
- She prefers lesser injections due to her busy daytime schedule.
- She has a history of admission for hypoglycaemia secondary to
sulphonylurea.
- She claims compliant with oral medications.
- No SMBG. Too busy with work and children.
- Insulin injection technique is satisfactory.
Questions:
1.
How would you change Mrs. A’s insulin regimen to suit her lifestyle and work nature?
● Since Mrs. A cannot comply with SC Mixtard® BD regimen, once-daily basal injection with
OGLDs may be considered.
● Suggest changing SC Mixtard® to SC Glargine U100 14 IU ON (starting dose 0.2 IU/kg)
and titrate accordingly.
● DPP4-i is preferred over sulphonylurea in view of her history of admission for
sulphonylurea-induced hypoglycaemia.
● Switch T. Metformin 1 g BD to T. Vildagliptin/Metformin 50/1000 mg BD.
2.
During subsequent visits, SC Glargine U100 dose was increased to 20 IU ON and HbA1c has
reduced to 7.4 %. However, patient still experiences hypoglycaemia but at a lesser
frequency than before, mostly nocturnal hypoglycaemia. What is your target HbA1c for
Mrs. A and is there any other insulin that you think would be better for her?
● HbA1c < 6.5 % (young, no other medical illnesses, no hypoglycaemia). If not achievable,
HbA1c < 7.0 % is acceptable.
● Suggest changing SC Glargine U100 to SC Glargine U300 20 IU ON as SC Glargine U300
has less hypoglycaemia risk as compared to SC Glargine U100.
● When switching SC Glargine U100 to Glargine U300, this can be done on a unit-to-unit
basis, but a higher Glargine U300 dose may be needed to achieve the target BG range
19 | C a s e s i m u l a t i o n s 2 0 2 3
(approximately 10 - 18 %). Close monitoring is recommended during the switch and in the
initial weeks thereafter so that dose can be titrated accordingly.
SC Glargine U300 was titrated up to 22 IU ON. HbA1c for the last 2 visits has improved to
7.1 % and 6.8 % with no hypoglycaemia.
Learning points:
•
•
De-escalation of insulin is to simplify, reduce or withdraw insulin to avoid
overtreatment and to minimize adverse events.
There may be a role for medication de-escalation. Reasons for this include
improvement in glycaemic control, successful weight loss (from lifestyle
intervention), change in glycaemic goals (especially in the setting of elderly
patients), development of new co-morbidities, development of intolerable side
effects, or treatment ineffectiveness.
References:
1. Ministry of Health; Malaysia (2020) "Clinical Practice Guidelines: Management of Type
2 Diabetes Mellitus (6th Edition)."
2. Ministry of Health; Malaysia (2011) "Practical Guide to Insulin Therapy in Type 2
Diabetes Mellitus (1st Edition)."
3. Product Information Leaflet: Toujeo®
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List of Abbreviations
2HPP
2-hour post prandial
BD
Twice daily
BG
Blood glucose
BMI
Body mass index
CGM
Continuous glucose monitoring
Cho
Cholesterol
DFIT
Dose, Frequency, Indication, Timing
DMTAC
Diabetes Medication Therapy Adherence Clinic
DPP4-i
Dipeptidyl-peptidase-4 inhibitor
eGFR
Estimated glomerular filtration rate
FPG
Fasting plasma glucose
HbA1c
Glycated hemoglobin
HDL
High density lipoprotein
LDL
Low density lipoprotein
MyMAAT
Malaysia Medication Adherence Assessment Tool
OD
Once daily
OGLD
Oral glucose lowering drug
21 | C a s e s i m u l a t i o n s 2 0 2 3
ON
Every night
SCr
Serum creatinine
SMBG
Self-monitoring blood glucose
T2DM
Type 2 Diabetes Mellitus
TDD
Total daily dose
TDS
Three times daily
TG
Triglyceride
UACR
Urine albumin-to-creatinine ratio
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