From the Guidelines
The best next step for this 30-year-old woman with type 1 diabetes is to use continuous glucose monitoring (option A). This patient is experiencing nocturnal hypoglycemia, as evidenced by her seizure due to hypoglycemia and reports of awakening with diaphoresis (night sweats), despite having seemingly adequate daytime glucose control (120-180 mg/dL) and a reasonable HbA1c of 7.2%. According to the most recent and highest quality study 1, integration of continuous glucose monitoring (CGM) into the treatment plan soon after diagnosis improves glycemic outcomes, decreases hypoglycemic events, and improves quality of life for individuals with type 1 diabetes.
Key Considerations
- The patient's history of nocturnal hypoglycemia and seizure due to hypoglycemia indicates a need for closer monitoring of glucose levels, particularly at night.
- The current monitoring schedule, which includes checks four times daily, may not be sufficient to detect overnight hypoglycemic episodes.
- Continuous glucose monitoring can provide real-time data on glucose levels, allowing for more accurate detection of hypoglycemia and adjustment of the insulin regimen as needed.
Benefits of Continuous Glucose Monitoring
- Improved detection of nocturnal hypoglycemia
- Reduced risk of hypoglycemic events
- Enhanced quality of life
- Ability to make data-driven adjustments to the insulin regimen
Comparison to Other Options
- Self-monitoring of glucose and adding another check at 3:00 AM (option B) may not provide the same level of continuous data as CGM.
- Referral for medical nutrition therapy (option C) may be beneficial, but does not directly address the patient's immediate need for closer glucose monitoring.
- Continuing current management (option D) is not recommended, as it has not prevented the patient's nocturnal hypoglycemia and seizure.
The use of CGM is now considered standard of care for most people with type 1 diabetes, as stated in the 2025 standards of care in diabetes 1. This approach directly addresses the specific clinical problem and is supported by the most recent and highest quality evidence.
From the FDA Drug Label
The time of occurrence of hypoglycemia depends on the action profile of the insulins used and may, therefore, change when the treatment regimen or timing of dosing is changed Patients should be informed about potential risks and advantages of LEVEMIR therapy, including the possible side effects Patients should be offered continued education and advice on insulin therapies, injection technique, life-style management, regular glucose monitoring, periodic glycosylated hemoglobin testing, recognition and management of hypo- and hyperglycemia, adherence to meal planning, complications of insulin therapy, timing of dosage, instruction for use of injection devices and proper storage of insulin Patients should be informed that frequent, patient-performed blood glucose measurements are needed to achieve effective glycemic control to avoid both hyperglycemia and hypoglycemia
The best next step is A. Continuous glucose monitoring. This is because the patient has a history of hypoglycemia and nocturnal symptoms (diaphoresis), indicating that her current monitoring regimen may not be sufficient to detect hypoglycemic episodes, especially at night. Continuous glucose monitoring can provide more detailed information about her glucose levels and help identify patterns or trends that may be contributing to her hypoglycemia 2.
From the Research
Next Steps for Managing Nocturnal Hypoglycemia
The patient's history of nocturnal hypoglycemia, as indicated by frequent awakenings with diaphoresis, suggests the need for closer monitoring of glucose levels during sleep. Considering the patient's current management and the evidence from recent studies, the following options are available:
- A. Continuous glucose monitoring: This approach has been shown to be effective in detecting and preventing nocturnal hypoglycemia 3, 4, 5, 6, 7. Continuous glucose monitoring (CGM) can provide real-time data on glucose levels, allowing for more accurate detection of hypoglycemic events and enabling timely interventions.
- B. Self-monitoring of glucose and adding another check at 3:00 AM: While self-monitoring of glucose is an essential aspect of diabetes management, adding an extra check at 3:00 AM may not be sufficient to detect all instances of nocturnal hypoglycemia. CGM has been shown to be more effective in detecting nocturnal hypoglycemia than traditional self-monitoring of glucose 4, 7.
- C. Referral for medical nutrition therapy: While medical nutrition therapy can be beneficial in managing diabetes, it may not directly address the issue of nocturnal hypoglycemia.
- D. Continue current management: Given the patient's history of nocturnal hypoglycemia, continuing the current management without any changes may not be the best approach.
Key Considerations
When deciding on the next steps, the following factors should be considered:
- The patient's history of nocturnal hypoglycemia and its potential consequences
- The effectiveness of CGM in detecting and preventing nocturnal hypoglycemia
- The patient's current management and its limitations in detecting nocturnal hypoglycemia
- The potential benefits of CGM in improving glucose control and reducing the risk of nocturnal hypoglycemia 3, 4, 5, 6, 7