Impact of a Clinical Pharmacist Regarding Correction of Insulin Use Before Possible Conversion from Traditional Insulin to U-500 Regular Insulin in a Patient With Uncontrolled Type 2 Diabetes

Abstract

This case presentation provides an illustration of the impact a clinical pharmacy specialist can have with regard to treatment planning, medication selection, and goal achievement in the management of a patient with grossly uncontrolled type 2 diabetes. A wheelchair-bound, 64-year-old white man presented to the pharmacist-managed metabolic clinic with a history of uncontrolled type 2 diabetes. The patient was referred by his primary care provider (PCP) for diabetes management and insulin adjustment, with the intention of eventually converting the patient from a traditional insulin therapy regimen to concentrated U-500 regular insulin. The patient had a history of metformin and glipizide combination therapy and was converted to a regimen of glargine and aspart when his oral medication regimen failed to control his diabetes. Glipizide therapy was discontinued when insulin was initiated in 2010, and metformin was discontinued in 2011 because of declining renal function. The patient's weight was 335.9 lb; his BMI was calculated to be 48.2 kg/m2. He reported currently smoking a pack of cigarettes per day with no intention of enrolling in a cessation program. He reported no alcohol or illicit drug use. During the intake interview, he reported a fair diet, with intake of simple carbohydrates being a prominent dietary source of glucose. He reported limited physical activity aside from wheelchair use. The patient also reported a positive family history for type 2 diabetes in his mother. His diagnosis list is shown in Table 1. View this table: Table 1. Current Diagnoses The patient's medication profile, as originally prescribed, is provided in Table 2. He reported poor adherence to his insulin regimen but close adherence to his oral medication regimen, aided by the use of a daily/weekly pillbox. When pressed for details about his insulin failure, he reported that he simply forgot to use both his basal and bolus …