HKDU Symposium > 2018 Update on Basal Insulin for Type 2 Diabetes 201802A
Dr. Wong Cheuk Lik
Specialist in Endocrinology, Diabetes & Metabolism (MCHK)

Direction: Choose the single best answer and give a tick in the corresponding box on the answer form.


1.

Which of the following benefit is most likely to be observed for the newer basal insulin analogue (IDeg U100 or IGlar U300) when compared to IGlar U100?


2.

A 55-year-old man has history of type 2 diabetes for 11 years. He also has history of hyperlipidemia, hypertension and mild renal impairment (eGFR 57ml/min/1.73m2). He has not had any macrovascular complication yet. He has been on metformin 500mg BD, pioglitazone 30mg daily and empagliflozin 25mg daily. His latest HbA1c was 8.7%. He has been recently started on basal insulin with IGlar U300. The following are the parameters for this gentleman:

 

Before insulin

3 months

6 months

Basal insulin dose (U/d)

-

16

26

HbA1c (%)

8.7%

8.2%

7.5%

Fasting glucose

9 mmol/L

7.0 mmol/L

3.8mmol/L

BW

80kg

81kg

82kg

 Which of the following would suggest over-basalisation in this gentleman?

1.          >0.25 U/kg/day on basal insulin

2.          Fasting glucose below target with HbA1c above target

3.          Nocturnal hypoglycemia

4.          Increasing body weight


3.

A 78-year-old lady has history of type 2 diabetes since 1986. She has been on BD insulin with metformin 500mg BD and sitagliptin 100mg daily for a few years. Her latest regime was protaphane 24units om and 12units pm. Her last HbA1c was 7.2%. She complained to you that she has been experiencing nocturnal hypoglycemia from time to time for the past few months. There were a few documented episodes of hypoglycemia with glucometer readings of 2.7mmol/L to 3.5mmol/L. Which of the following action is the most appropriate for her in terms of further insulin adjustment?


4.

A 49-year-old gentleman has history of type 2 diabetes since 6 years ago. Three months ago, he had an HbA1c of 9.0%. Current medications include metformin 1gm BD, linagliptin 5mg daily, atorvastatin 20mg daily and lisinopril 10mg daily. He admits irregular diet pattern and suboptimal diet control. He didn’t have self monitoring of blood glucose (SMBG). Physical examination: body weight – 78kg; BMI 28kg/m2, BP 132/ 80-mmHg. eGFR >90ml/min/1.73m2. Lipid profiles – LDL-C 3.2 mmol/L and HDL-C 1.0mmol/L. After some discussion, he agrees to start IDeg as basal insulin and perform SMBG. He calls you 5 days later to ask if he should increase his insulin dose. The following shows his present regime and SMBG:

 Degludec U-100: 10 units every morning

SMBG:    Monday   10.1 mmol/dL  Tuesday  9.1 mmol/L

             Wednesday 8.5 mmol/L    Thursday 8.2 mmol/L

             Friday        8.7 mmol/L

 What do you recommend?


5.

A 62-year-old lady was diagnosed with type 2 diabetes 12 years ago. She presents to the emergency department for chest pain. Her current medications include insulin glargine U-300 – 60 units once daily, insulin aspart 20 units tds, perindopril 4mg daily, nebivolol 10mg daily, rosuvastatin 10mg daily and metformin 1gm BD. Physical examination is unremarkable and ECG does not show any acute ischemic changes. She is then admitted for further monitoring and investigation. She reports her fasting glucometer readings to be ~6-9 mmol/L. Her last HbA1c was 8.0% 2 months ago. However, there is only glargine U-100 in the hospital drug formulary. What dose would be appropriate to start this lady on?