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The importance of continuous glucose monitoring when transitioning a patient from insulin detemir to U-500R

Connie A Valdez*, Leah Fitzgerald & Sarah Ziherl Hormachea

Introduction: Continuous glucose monitoring (CGM) is especially valuable when intensifying insulin in challenging and high risk patients to determine recurring patterns of unrecognized hypoglycemia and excursions of hyperglycemia. In this report, we describe the use of CGM in a patient with severe insulin resistant type 2 diabetes who was transitioned from insulin detemir to U-500R and illustrate how CGM was instrumental in helping find the ideal insulin regimen.

Case study: The patient is a 66 year-old obese Native American woman with a 17- year history of type 2 diabetes mellitus and severe insulin resistance. Despite escalating U-100 insulin detemir up to 230 units per day, her diabetes was still uncontrolled. To fully appreciate the patient’s blood glucose (BG) levels over a 24-hour period, she agreed to wear a CGM for two weeks. The CGM estimated an A1C of 11.8% with a time in goal range (70-180 mg/dl) at only 11%. The patient was transitioned to U-500R with an initial dose of 0.22 mL (110 units) 30 minutes before breakfast and 0.15 mL (75 units) 30 minutes before dinner. Her dose was ultimately titrated to 0.23 mL (115 units) in the morning and 0.15 mL (75 units) in the evening. In order to validate safety of her new U-500R regimen and assess her diabetes control, she scheduled a follow-up visit, which included placement of another CGM. The new estimated A1C was 7.0% and the patient’s BG values were within the goal range during the majority of the day. There were 7 possible episodes of hypoglycemia, all which occurred between 1 am-7 am.

Conclusion: CGM is a valuable tool that can aid in the evaluation of BG values and help formulate safe and effective insulin regimens, especially for patients who have difficulty obtaining adequate glucose control and in patients who are initiated on U-500R.