Patient case 3b.

Switching to degludec from pump therapy due to a desire for a more discreet treatment

Name: Anna	A1C: 8.0% (63.9 mmol/mol)
Age: 17 years	ICR: 1 unit per 8 g with breakfast, 1 unit per 10 g with other meals; 1 unit per 12 g before or after exercise
Body weight: 57 kg
Previous basal dose: 24 units/day
Case history   Anna is an active teenager and has been living with diabetes for 8 years. She has been on a pump most of that time, but is keen to have a less “visible” therapy. In general, she is moderately adherent to her diabetes care, performing 3–4 SMBG measurements daily. She remembers insulin boluses, unless she is on a night out with friends, when she will tend to skip boluses, because of anxiety about possible hypoglycemia. Although Anna has suboptimal glycemic control, she changes pump catheter regularly and does not interrupt basal rate. Therefore, the switch to degludec can be based on her previous daily basal dose
Guidance   Although pump therapy has been reported to improve glycemic control and reduce the risk of hypoglycemia and hospitalization for DKA [31, 32], Anna is not in good control as a result of skipped boluses. Instead of using frequent prandial and correction bolus doses, which is associated with better HbA1c, she applies infrequent large corrections. Consequently, Anna still has marked hypo- and hyperglycemia, and potentially DKA. Her fasting glucose was usually satisfactory. Switching to degludec was advised   Anna was commenced on degludec 24 units once daily (0.42 units/kg) (no dose reduction because of still pubertal high insulin need) with the same ICR   She was strongly encouraged not to skip bolus doses   She was educated about alcohol and diabetes, and also counseled regarding pregnancy and diabetes