Hyperinsulinemia

1
Hyperinsulinemia
2

• G.O.is a 42-year old, slightly obese (5'11", 180
  IB) male who has had a history of IDDM for 19
  years .G.O.'S medical care was sporadic until one
  year ago when he referred himself to the
  university's dibetes clinic because he was
  beginning to develop pain and numbness in his
  feet .at that time, he was poorly controlled on a
  single daily dose of 45 units of NPH insulin. He
  had not been testing his urine or blood glucose
  concentrations and his glycosylated hemoglobin
  level was 13.

3

• On physical examination
• 1) he was found to have an elevated blood
  pressure (160/94 mmHg)
• 2)back ground retinopathy, and decreased pedal
  pulses.
• 3)There was decrease sensation to vibration and
  pin prick in both feet.
• The patient complained of
• 1) impotence and "shooting pains" in both legs.
• 2) A 24-houre collection of urine protein
  contained 1.5 grams of albumin.

4

• G.O. was treated with multiple daily doses of
  insulin. Over the last several months, he has
  been treated with the following regimen
• 12 U lente/10-12 U regular before
• breakfast 10-12 U regular before lunch and 24U
  lente at bedtime.
• Blood glucose concentrations have been as
  follows
• Time glucose (mg/dL)
• 7 a.m. 100-150
• 12 p.m. 280
• 5 p.m. 40-280

5

• Over the past year, G.O.'s glycosylated
  hemoglobin has decreased to 7.2. Currently, he
  has approximately 5 hypoglycemic reactions per
  week primarily in the late afternoon and
  evenings. He has found that he can avoid
  nocturnal hypoglycemia by eating a large, bedtime
  snack. Over the past three months, he has gained
  15 pound. Evaluate G.O.S' overall control.
• What interventions are indicated at this time?
• G.O. illustrates one of the major hazards of
  intensive insulin therapy hypoglycemia and
  hyperinsulinemia.

6

• The signs and symptoms of over insulinization in
  G.O. include
• 1. A total daily insulin dose of almost 0.9
  units/kg. This dose is unusual in a patient with
  type I diabet.
• 2. A weight gain over the past several months.
  This is secondary to the anabolic effects of
  insulin as well as G.O.s' increased carbohydrate
  intake to match his high insulin doses.
• 3. Frequent hypoglycemic reactions.
• 4. An apparently "brittle" situation. That is,
  blood glucose concentrations which fluctuate
  wildly between hypoglycemia and hyperglycemia. In
  G.O.s' case, high blood glucose concentrations
  may represent reactive hypoglycemia or
  overtreatment of hypoglycemic episodes.

7

• 5. Normal glycosylated hemoglobin levels
  indicated mean blood glucose concentrations which
  must be within the normal range even though the
  patient has recorded numerous high blood glucose
  concentrations. In a large scale study of
  patients treated with continuous subcutaneous
  insulin infusion or multiple daily doses of
  insulin, severe hypoglycemic episodes and coma
  were two to three times more common than in
  patients treated with standard insulin therapy.

8
Management of hyperinsulinemia

• G.O. should be managed by
• 1) gradually decreasing his insulin doses.
• 2) Since most of his reactions are occurring in
  the late afternoon and evening, the morning dose
  of intermediate-acting insulin should be adjusted
  first.
• a)One should also consider changing his
  intermediate-acting insulin from lente to NPH
  insulin,
• b) since the excess zinc in the lente insulin May
  covert some of the short-acting insulin to an
  intermediate-acting form.
• 3) The bedtime dose of intermediate-acting
  insulin should also be reduced since the patient
  has reported episodes of nocturnal hypoglycemia.
• Thus, a Total reduction of 6 to 7 units is
  appropriate (e.g., a reduction in the morning
  dose of intermediate-acting insulin to 10 units
  and a reduction in the bedtime intermediate-acting
  insulin to 20 units.
• Caution reduction in the insulin dose ( 10 at a
  time ) to avoid hyperglycemia and ketonemia

9

• In addition
• 4) G.O. should begin testing his glucose
  concentrations at 300 a.m. and be taught to
  treat his hypoglycemic episodes appropriately.
• If he is capable, an algorithm for adjusting his
  pre-prandial regular insulin doses should be
  provided to minimize hypoglycemic reactions.
• An example of an algorithm which may be
  appropriate for G.O. follows
• Blood glucose
• (Mg/dL) CHANGE DOSE OF
  REGULAR INSULIN BY
• lt60 -2 U
• lt80 -1 U
• 80-140 no change
• 140-170 1 U
• 170-200 2 U
• 200-230 3 U
• gt230 4 U