Educating Patients About Hypoglycemia Prevention and Self-Management

Abstract

Mrs. B was a 68-year-old, Asian-American woman with a 15-year history of type 2 diabetes. Her coexisting medical conditions included unilateral intraductal carcinoma of the breast, which was treated with a modified radical mastectomy 6 years ago and showed no evidence of recurrence. Although there was no history of alcohol use, her liver function studies had been elevated to two times the upper limit of normal for several years. A liver biopsy revealed the presence of nonalcoholic steatohepatitis (NASH). She was admitted to the hospital on one occasion within the past year for bleeding esophageal varices. Mrs. B had no history of macrovascular disease, chronic kidney disease, retinopathy, or neuropathy. For the past 10 years, she had taken 10 mg glyburide daily. Her primary care provider (PCP) was concerned that her A1C had increased from 7.4 to 7.9% in the past 6 months. Her family members stated that they rarely spoke about diabetes, self-monitoring of blood glucose (SMBG), or diabetes-related complications. In fact, the patient's 72-year-old husband also has type 2 diabetes and is undergoing dialysis. In the past year, Mr. B has had at least two episodes of severe hypoglycemia that required hospitalization. He blames his end-stage renal disease on medication he is taking to control his blood glucose levels. Because of concerns about Mrs. B's increasing A1C, her PCP asked her to consult with a local endocrinologist who added basal insulin to her diabetes treatment regimen. She was not provided with any specific instructions about how to inject the basal insulin or when to perform SMBG. Her son noted that she tended to get “confused,” but he did not attribute this to her blood glucose level because he never saw her checking her glucose. Her handwritten glucose log showed several readings in the low 50 to 60 mg/dl …