We describe a 37-year-old woman with a BMI of 32 kg/m2 who presented with poorly controlled type 2 diabetes (HbA1c of 10.3%). She was requiring 138 units of insulin (Aspart 20, 24 and 30 units pre meal and glargine 64 units at night daily). She previously had diarrhoea with metformin and an allergic reaction to glimepiride. Rosiglitazone was discontinued because of worsening liver function. Her insulin requirement increased in a year to 1650 units daily owing to insulin resistance. She was receiving actrapid 250, 350 and 350 units pre meal and humulin I (changed from glargine) 400 units in the morning and 300 units in the evening. She was commenced on U-500 actrapid insulin to ameliorate the discomfort in sustaining daily insulin injection of 16.5 ml. Subsequently she was tried on pramlintide (symlin) 30 mcg s/c before each meal containing at least 30 g of carbohydrate, while still on insulin. Four months later the patient was on U-500 actrapid 250, 300 and 250 units pre meal and humulin I 250 units in the morning and 200 units in the evening with pramlintide of 180 mcg before each meal (containing at least 30 g of carbohydrate). She lost 5 kg following administration of pramlintide with only slight reduction in her insulin requirement. Her HbA1c was 8.2%. Thereafter she was commenced on CSII (continuous subcutaneous insulin infusion) while still on pramlintide. Later she came off pramlintide and is currently on CSII alone requiring much lesser dose of insulin:U-500 actrapid 1.6 units/h between 0 and 5 h, 1.5 units/h between 5 and 8, 3 units/h between 8 and 9 and 4.7 units/hour at other times of the day (total daily basal dose: 430 units) with a bolus dose of 0.6 units for every 10 g of carbohydrate and with better control of her diabetes(HbA1c 7.5%).
03 - 07 May 2008
European Society of Endocrinology