In 1993, Ross Adler of Lakewood, Washington, was 58 years old and taking a four-shot-per-day regimen of NPH and Regular insulin for a total of 110 units per day. His HbA1c was 8.4%, and his fasting C-peptide was 3 ng/mL which strongly suggested type 2 diabetes was caused by insulin resistance. Obviously, with such a high HbA1c, his injected insulin was not lowering his blood sugars.
Adler had learned carbohydrate counting from a nutritionist, and even joined a health club to begin a regular exercise program. Over the next four years, his HbA1c remained between 8.5 and 9%, and in 1997 he developed his first of two episodes of severe hypoglycemia. One episode required emergency treatment by paramedics.
By 1998, Adler’s diabetes control had not improved despite frequent blood sugar monitoring, a multiple injection regimen, use of lispro insulin, various combinations of glyburide, Glucophage, Precose and Rezulin, and a regular exercise program. Adler’s overall BG average was 190 mg/dl, but was totally unpredictable.
After much discussion with his family and diabetes team, Adler decided to see if he could achieve better blood glucose levels through the use of an insulin pump.
In May 1998, Adler, whose HbA1c was now 8.2%, started using an insulin pump. The first thing he noticed was a significant reduction in the amount of insulin needed. His pre-pump dose of 110 units per day was reduced to 90 units per day. His basal rate was 45 units per day or 1.9 units per hour. His diabetes management included two basal rates, continued carbohydrate counting and use of a temporary basal rate for exercise.
After about two weeks, Adler’s basal dose stabilized at 1.8 units per hour, and his total daily dose was about 85 units per day. This was a reduction of 25 units per day. By October 1998, his BG average was 155 mg/dl, a reduction of 35 mg/dl. At 7.4%, Adler’s HbA1c was the lowest it had ever been.
A Lot of Living Left to Do
“The pump has helped me immensely,” says Adler. “I have a lot of living left to do. I worry less about complications from diabetes, and my attitude is better. I don’t have to worry about eating on time, in fact, now I just have two meals a day: breakfast and dinner. Last week, my wife and I went to Las Vegas, where we were eating out all the time, and only three out of the 28 blood sugar readings for that week were out of my target range.”
Adler’s wife reports, “Prior to the pump, he would drive himself nuts trying to figure out what was wrong when his BGs were high or low. Now, he seems to be a happier person and seems to have more energy.”
Hirsch writes that this case “illustrates how [insulin pump therapy] can be as beneficial for certain patients with type 2 diabetes as it is with type 1 diabetes.” He adds that “some patients with type 2 diabetes cannot be controlled well, even with multiple injections in combination with oral agents.”
Hirsch points out that Adler’s diabetes team could have discussed insulin pump therapy sooner, but due to a lack of experience with this population’s using insulin pumps, it had not even occurred to them.
Hirsch emphasizes that with the publication of the United Kingdom Prospective Diabetes Study in 1998, there should be less concern about using insulin in type 2 patients.
“For many patients,” he writes, “[insulin pump therapy] should be considered as an important option.”
This case study was presented by Irl B. Hirsch, MD, associate professor of medicine at the University of Washington and medical director of the Diabetes Care Center at the university’s medical center in Seattle.