Patient case 3a.

Switching to degludec as a result of poor adherence to pump therapy

Name: Miguel	A1C: 9.8% (83.6 mmol/mol)
Age: 15 years	ICR: 1 unit per 10 g
Body weight: 65 kg
Previous basal dose: 28 units/day (0.43 units/kg)
Total daily dose: 44 units/day
Case history   Miguel recently had a hospital admission with DKA. His adherence to bolus insulin dosing is not optimal (1–2 boluses per day) and his glucose testing is inadequate (0–2 tests daily), hence he did not recognize his pump had failed as a result of cannula occlusion. Miguel agreed that a pump was not the best option for him at present
Guidance   As Miguel has had issues with adherence, particularly with self-measuring of BG, his basal insulin requirement was recalculated and he received appropriate psychological support and education to help him meet his glycemic targets. As there is often limited information available from non-adherent patients, the added complexity often makes it advisable to start afresh with weight-based insulin dosing (e.g., 40% of body weight for the basal insulin dose). Miguel has a high proportion of his total daily dose determined by his basal insulin (> 60% when it should optimally be 40–50% of total); likely increased to make up for skipped bolus injections   As Miguel was on too much basal insulin, he was started on 25 units/day (0.38 units/kg) of insulin degludec 100 units/mL and 1 unit insulin aspart per 10 g carbohydrate. Flash glucose monitoring was used to facilitate titration of his insulin doses