What is the appropriate management for a 68-year-old female patient with diabetes mellitus, hyperlipidemia, and hemorrhoids, who is taking Mounjaro (tirzepatide) Solution Pen-injector, Tresiba (insulin degludec) FlexTouch Solution Pen-injector, metFORMIN HCl (metformin) ER, and Jardiance (empagliflozin) Tablet, and presents with hypoglycemia after self-administering 25 units of insulin, despite being prescribed 7 units, with reported blood glucose readings of average 155 mg/dL, highest 422 mg/dL, and lowest 52 mg/dL, and experiencing diarrhea and a rash on her chest?

From the Guidelines

This patient should immediately return to her prescribed 7 units of Tresiba insulin and not self-adjust her dosage, as taking 25 units when prescribed 7 units caused her hypoglycemic episode, which explains her shakiness, and is in line with the recommendations for managing hypoglycemia outlined in the 2023 standards of care in diabetes 1. The patient's blood sugar readings show poor control, with an average of 155 mg/dL and extreme fluctuations from 52 to 422 mg/dL, indicating the need for medication adjustment and better patient education on diabetes management.

• The provider's decision to stop insulin, increase Mounjaro, and increase metformin is appropriate to stabilize her glucose levels, as it addresses the issue of hypoglycemia and aims to improve glycemic control.
• The patient should be educated on recognizing hypoglycemia symptoms, such as shakiness, and when to seek medical help rather than self-adjusting medications, as outlined in the recommendations for hypoglycemia management 1.
• Regarding her rash, she should be evaluated by her healthcare provider before discontinuing any medication due to suspected allergic reaction, to determine the cause of the rash and the best course of action.
• The diarrhea may be related to increased metformin dosage, which is a common side effect that often resolves with time, but the patient should be monitored for any further gastrointestinal symptoms.
• The patient's hypoglycemic episode, with a blood sugar reading of 52 mg/dL, meets the definition of level 2 hypoglycemia, which requires immediate action to resolve the hypoglycemic event, and warrants investigation and review of the treatment plan, as recommended in the 2023 standards of care in diabetes 1.

From the FDA Drug Label

If you take too much Levemir, your blood sugar may fall low (hypoglycemia). You can treat mild low blood sugar (hypoglycemia) by drinking or eating something sugary right away (fruit juice, sugar candies, or glucose tablets). It is important to treat low blood sugar (hypoglycemia) right away because it could get worse and you could pass out (become unconscious) If you pass out you will need help from another person or emergency medical services right away, and will need treatment with a glucagon injection or treatment at a hospital. Symptoms of low blood sugar may include: sweating trouble concentrating or confusion dizziness or lightheadedness blurred vision shakiness slurred speech hunger anxiety, irritability or mood changes fast heart beat headache tingling of lips and tongue

The patient's symptoms of shakiness after taking 25 units of insulin are consistent with hypoglycemia, which is a possible side effect of taking too much insulin. The patient should be advised to treat mild low blood sugar by consuming something sugary right away and to seek help if symptoms worsen or if they experience severe hypoglycemia. 2

Key points:

• The patient took 25 units of insulin, which is more than the prescribed 7 units.
• The patient experienced shakiness, a symptom of hypoglycemia.
• Hypoglycemia can be treated with something sugary, but severe cases require medical attention.
• The patient should be cautious when taking insulin and follow the prescribed dosage to avoid hypoglycemia.

From the Research

Patient's Blood Sugar Management

• The patient is taking Mounjaro Solution Pen-injector, Tresiba FlexTouch Solution Pen-injector, metFORMIN HCl ER, and Jardiance Tablet to manage her blood sugar levels 3.
• She reports taking 25 units of insulin, which led to low blood sugar and shakiness, despite being prescribed 7 units 4.
• The patient's average blood glucose reading is 155 mg/dL, with the highest reading being 422 mg/dL and the lowest being 52 mg/dL.

Medication Errors and Safety

• Insulin-related medication errors can have serious consequences, including overdose, hypoglycemia, and even death 4.
• The use of abbreviations, such as "U" instead of "units", can lead to wrong-dose errors and overdose 4.
• Electronic prescribing can also lead to errors due to the sheer number of insulin products and software incompatibility 4.

Combination Therapy for Type 2 Diabetes

• The combination of empagliflozin and metformin therapy has been shown to be effective and well-tolerated in patients with type 2 diabetes 5.
• This combination offers the potential to improve glycemic control, reduce body weight and blood pressure, and has a manageable risk profile 5.
• Empagliflozin has been proven superior to placebo for reduction of cardiovascular disease risk and has a low risk of hypoglycemia 6.

Dosing and Titration of Insulin

• Adequate insulin dosing is crucial to achieving good glycemic control with minimal hypoglycemia 7.
• Dose titration immediately following insulin initiation is needed to ensure its success, and patient-managed titration can lead to greater reductions in HbA1c 7.
• The choice between titration algorithms may depend on clinical circumstance and a patient's willingness and ability to become more involved in management of therapy 7.