Endo 1: You get a DATE if you treat her RIGHT !! - triplehelix

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d

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correct answer is D.

Generally speaking, more complex regimens with more frequent injections of both short/rapid and long/intermediate acting insulins result in better control, as long as the patient has the required motivation and capacities. This patient has suboptimal glucose control on premixed (intermediate- plus rapid-acting) insulin administered twice daily. Premixed insulins, although convenient, lack the more precise dosing flexibility of self-mixed or individually administered insulins. High glucose levels in the fasting period suggest the need for greater insulin exposure during that time period. However, the overnight hypoglycemia episodes prevent increasing the evening insulin dose. Indeed, these episodes likely affect the peak of the intermediate protamine lispro administered before dinner. Increasing the dose of the morning premixed insulin and decreasing the dose in the evening may result in better glucose levels during the day and may decrease overnight hypoglycemia. However, fasting glucose levels are likely to worsen. Increasing both insulin doses will probably increase the hypoglycemic episodes overnight. Self-adjusted and self-mixed insulin (NPH and lispro) may provide more flexibility, but NPH at dinner will have a similar pharmacokinetic profile to protamine lispro. As a result, this change will do little to counteract her hypoglycemia overnight. Reducing calorie consumption is an inappropriate recommendation to a normal weight person with type 1 diabetes, although proper food choices may improve control to some degree. This patient will derive the most benefit from switching to an aggressive regimen of glargine at bedtime, providing 24 hours of basal insulin, with three adjusted doses of the rapid-acting lispro insulin at mealtime to prevent postprandial glucose excursions. Another possible option that may improve matters is to provide self-mixed NPH plus a rapid-acting insulin analogue, such as lispro, in the morning, then the analogue alone before supper, and a second dose of NPH at bedtime. The later administration of NPH may allow for its peak to occur closer to the early morning period, which may control the fasting readings to a better degree and reduce overnight hypoglycemia.