Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 48-year-old woman returns for a follow-up visit for management of type 1 diabetes mellitus. She reports doing well since the last visit. Overall, she believes that most of her blood glucose levels are at goal, but is concerned about occasional episodes of hyperglycemia occurring in the morning before breakfast. She eats a bedtime snack every night that is not covered with mealtime insulin. Review of her blood glucose log demonstrates morning fasting blood glucose values from 80 to 190 mg/dL (4.4 to 10.5 mmol/L). Her other premeal and bedtime values range from 100 to 120 mg/dL (5.5 to 6.7 mmol/L). She exercises two to three times per week in the evening. Medical history is significant for hypertension and hyperlipidemia.
Medications are insulin glargine, insulin lispro, ramipril, simvastatin, and aspirin.
On physical examination, blood pressure is 130/72 mm Hg and pulse rate is 67/min. BMI is 24. The remainder of the examination is unremarkable.
Results of laboratory studies show an HbA1c level of 6.9% and serum creatinine level of 1.0 mg/dL (88.4 µmol/L). Serum electrolytes are normal.
Which of the following is the most appropriate management of this patient’s occasional fasting hyperglycemia?
A. Add insulin lispro at bedtime
B. Add metformin
C. Increase insulin glargine dose
D. Measure 3 a.m. blood glucose level
E. Continue current regimen
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