What are the treatment options for a patient with type 1 diabetes, taking long-acting insulin (e.g. glargine) and sliding scale, preprandial insulin, with consistently high blood glucose levels (hyperglycemia) and occasional overnight hypoglycemia, who has dementia and uses a continuous glucose monitor (CGM)?

From the Guidelines

For a patient with type 1 diabetes who has dementia, uses a CGM, takes long-acting insulin with sliding scale preprandial insulin, and experiences consistent hyperglycemia with occasional overnight hypoglycemia, I strongly recommend transitioning to a basal-bolus insulin regimen with simplified dosing, as this approach has been shown to improve glycemic control and reduce the risk of hypoglycemia 1. The patient should continue using glargine as the basal insulin but with a 10-20% reduction in the overnight dose to address nocturnal hypoglycemia. For mealtime coverage, switch from sliding scale to fixed preprandial doses of rapid-acting insulin (like lispro, aspart, or glulisine) based on consistent carbohydrate counting, starting at approximately 1 unit per 10-15g of carbohydrates, as recommended for individuals with type 1 diabetes 1. Consider implementing a simplified insulin regimen with pre-mixed insulins for caregivers to administer if the patient's dementia affects their ability to manage multiple daily injections. The CGM should be used to establish patterns and make regimen adjustments, with alerts set for both high and low glucose values, as CGM has been shown to be a useful tool in managing type 1 diabetes, especially in those with hypoglycemia unawareness or frequent hypoglycemic episodes 1. Caregivers should be trained to interpret CGM data and respond appropriately, including the administration of glucose or carbohydrate-containing food to treat hypoglycemia, with 15-20g of glucose being the preferred initial treatment 1. This approach addresses the hyperglycemia by providing more consistent insulin coverage throughout the day while reducing the risk of overnight hypoglycemia through basal dose adjustment, and acknowledges the cognitive limitations imposed by dementia while leveraging the CGM technology to improve safety and glycemic control. Key considerations include:

• Regular assessment of cognitive function and vigilance for hypoglycemia
• Adjusting the treatment regimen to avoid further hypoglycemia and partially reverse hypoglycemia unawareness
• Prescribing glucagon for individuals at increased risk of severe hypoglycemia and instructing caregivers on its administration 1. By prioritizing the patient's safety and glycemic control, this approach aims to minimize morbidity, mortality, and improve quality of life.

From the FDA Drug Label

Insulin requirements may be reduced in the presence of drugs that lower blood glucose or affect how your body responds to insulin... Hypoglycemia (too little glucose in the blood) is one of the most frequent adverse events experienced by insulin users. Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin

The patient's consistently high blood glucose levels and occasional overnight hypoglycemia suggest that the current insulin regimen may need to be adjusted. Treatment options may include:

• Adjusting the dose or timing of the long-acting insulin and sliding scale, preprandial insulin
• Monitoring blood glucose levels more frequently, especially before activities such as driving
• Eating or drinking sugar-containing foods to treat hypoglycemia
• Considering changes in therapy, meal plans, and/or exercise programs to help avoid hypoglycemia 2 It is recommended to discuss these options with the patient's doctor to determine the best course of action.

From the Research

Treatment Options for Type 1 Diabetes with Hyperglycemia and Hypoglycemia

The patient's current treatment regimen includes long-acting insulin, sliding scale, preprandial insulin, and a set amount of insulin preprandially, but is experiencing consistently high blood glucose levels and occasional overnight hypoglycemia. Considering the patient's dementia and use of a continuous glucose monitor (CGM), the following treatment options can be explored:

• Adjusting the insulin regimen to better match the patient's glucose levels and lifestyle, as suggested by 3 and 4
• Using a more flexible insulin regimen, such as a basal-bolus regimen, to allow for more precise control of glucose levels, as recommended by 3
• Adding a sodium-glucose cotransporter 2 (SGLT2) inhibitor to the treatment regimen, which has been shown to improve glycemic control in patients with type 1 diabetes, as demonstrated by 5
• Implementing algorithms for adjustment of insulin dosage based on patient-determined blood glucose measurements, as described by 6
• Intensifying insulin treatment through options such as changing the insulin regimen or adding additional medications, while considering patient willingness, overall health status, and risk of hypoglycemia, as discussed by 7

Considerations for Insulin Regimen Adjustment

When adjusting the insulin regimen, it is essential to consider the following factors:

• The patient's glucose levels and lifestyle, including meal patterns and routines
• The risk of hypoglycemia and hyperglycemia, and the need to balance these risks
• The patient's willingness and ability to adhere to the treatment regimen
• The potential benefits and drawbacks of different insulin regimens and medications, including SGLT2 inhibitors

Role of Continuous Glucose Monitoring

The patient's use of a CGM can provide valuable insights into their glucose levels and patterns, allowing for more informed decisions about insulin regimen adjustments. The CGM data can be used to:

• Identify patterns of hyperglycemia and hypoglycemia
• Inform adjustments to the insulin regimen
• Monitor the effectiveness of treatment changes
• Provide feedback to the patient and healthcare team to support ongoing management and adjustment of the treatment plan, as recommended by 3 and 5