Case Study:

Daniel

Daniel is a retired baker who still likes to bake and cook.

He’s concerned about regular overnight hypoglycaemia and consequently chasing sugars in the morning. Read about how Daniel and his Healthcare Team use the FreeStyle Libre 2 system and LibreView to minimise overnight hypoglycaemia and manage exceptional hyperglycaemic swings in the morning.

Patient Image - Daniel
Patient Image - Daniel
Patient Image - Daniel

About Daniel

Summary

Daniel is a retired baker who still likes to bake and cook. He is concerned about his regular overnight episodes of hypoglycaemia and consequently chasing his sugars in the morning.

Comorbidities

High cholesterol, hypertension; currently prescribed ramipril and simvastatin.

Specific Objective

The key goals are to minimise overnight hypoglycaemia and manage his exceptional hyperglycaemic swing in the mornings.

Age67BMI28.1 kg/m2
Diabetes (Type)Type 1 diabetesLast HbA1c value57.4 mmol/mol (7.4%)
ProfessionRetired bakerTarget glucose range3.9-10 mmol
Duration of diabetes37 yearsTreatmentBasal-bolus insulin therapy

Consultation One

What does the four step review tell us?

Data capture and Time in Range (TIR)

Daniel scans very regularly and his sensor data capture at 95% has helped in obtaining a good AGP Report. His Time in Range is 48%, but given his age and duration of diabetes, this is not a concern.

Daniel - AGP Report

Look for patterns of hypoglycaemia

Daniel’s Time Below Range is poor at 10% which is well above the recommended target of less-than 4%. Also, his AGP shows a consistent drop in glucose overnight from midnight through to 6:00am, and his Snapshot report shows with significant low glucose events in this period. There is another steep fall towards the low-glucose zone around 12:00pm–2:00pm, again associated with low glucose events. His glucose variability later in the day also puts him at risk of hypoglycaemia at these times. These trends are a priority for management.

Daniel - Snapshot

Look for patterns of hyperglycaemia

The most striking aspect of Daniel’s AGP is the major spike in glucose in the morning between 6:00am and noon. His Daily Patterns report shows that his average glucose level at this time is 18.1 mmol/L. Adjusting his prandial insulin dose and timing before breakfast should be a priority of this consultation. The blue and grey bands show variability well above the target range throughout the afternoon and into the evening, with a poor time above target performance of 42%.

Daniel - AGP Report

Look for patterns of glucose variability

The blue and grey bands in Daniel’s AGP are fairly narrow through the night and morning until noon, after which they widen through much of the afternoon and evening. This indicates that Daniel is not matching his insulin needs to his meals and snacks, as well as his activities on some days. His glucose is unstable during the day, including the spike after breakfast. This suggests that Daniel should be advised to consider his insulin, his diet and his daily activities.

What actions might you agree with Daniel?

  • Daniel’s prandial insulin dose should be increased to moderate the large post- breakfast glucose excursion. The timing of this bolus also needs to be considered.

  • Reducing Daniel’s correction-dose calculation in response to his glucose spike may help minimise the steep fall into the low-glucose zone.

  • Daniel is a baker and loves cooking. There is a need to discuss his lifestyle and eating behaviour to address the lifestyle-related variability as revealed by the wide grey shaded band.

Daniel - AGP Report

Consultation Two

What does the four step review tell us?

Data capture and Time in Range (TIR)

Daniel’s data capture is still excellent at 94% and his Time in Range has increased to 58%. These are positive outcomes from his last review, he can be pleased with his progress.

Daniel - AGP Report

Look for patterns of hypoglycaemia

Daniel’s overnight lows are still a priority as his glucose is still consistently falling overnight. If anything, it is more of a concern as his median line and blue shaded band are dropping below target between midnight and 6:00am, with low glucose events overnight with some readings below 3.0 mmol/L. His trough between late-morning to early afternoon is still a cause for concern, between 10:00am – 2:00pm. These low-glucose problems are confirmed by the fact that his time below target has increased to 13% and requires immediate intervention.

Daniel - Snapshot

Look for patterns of hyperglycaemia

The changes in Daniel’s treatment have reduced the morning glucose spike significantly, with average glucose levels within his target range, which is really encouraging. However, the blue median line and blue shaded band of variability are swinging upwards above Daniel’s target range from 1:00pm–9:00pm and should be addressed. His time above range has reduced significantly from to 42% to 26%, good progress, but it still needs to improve further.

Daniel - AGP Report

Look for patterns of glucose variability

The variability shown by the blue and grey bands in Daniel’s AGP has improved in the morning, but both are still ballooning in the evening, indicating high glucose variability, most notably between 4:00pm–9:00pm.

What actions might you agree with Daniel?

  • Daniel’s basal insulin should be reduced to address the hypoglycaemic trend during the second half of the night and morning.

  • Changes to his mealtime insulin can be assessed once the change to his basal insulin can be reviewed.

  • The ballooning grey shaded band throughout the afternoon and evening suggests that Daniel needs to be more consistent in his eating habits and his social activities on different days.

Daniel - AGP Report

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References & Disclaimers 
Images are for illustrative purposes only. Not actual patient or data.

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