Endocrine Abstracts

We present the case of an 83-year-old woman with a medical history of moderate-severe Alzheimer’s disease, which made her dependent. Despite this, she was able to communicate and go out in a wheelchair. Over the last 6 months, she experienced decreased intake and lost more than 10% of her body weight. In addition, she was diagnosed in 2006 with latent autoimmune diabetes of adults (LADA), treated initially with oral antidiabetic agents but later on, it was necessary to switch to insulin therapy and glucose monitoring. She presented difficult glycemic control with episodes of hypoglycemia due to refusal to eat after administration of rapid-acting insulin, even requiring emergency services care for severe hypoglycemia in some of these episodes. Thus, the family began to skip insulin doses due to fear of new hypoglycemic events. The sensor discharge data were TAR 50%, TIR 41%, TBR 9% (very low 1%). In mid-2023, the patient was transferred to the emergency room due to poor general condition and impaired level of consciousness. Blood test revealed a glycemia of 560 mg/dl, metabolic acidosis, and positive urine ketone bodies, leading to a diagnosis of diabetic ketoacidosis and intensive fluid therapy and intravenous insulin perfusion were initiated. Once stabilized, she was admitted to the unit. On the hospital ward, intakes continued to be erratic, again presenting severe hypoglycemias that led to a reduction in insulin doses and subsequently resulted in hyperglycemia of >300 mg/dl when adequate intakes were taken. Finally, it was decided that the most appropriate approach was to initiate enteral nutrition by PEG, as this would improve nutritional status by guaranteeing adequate caloric intake and hydration, along with a fixed carbohydrate intake, enabling the administration of a consistent insulin dose at all times. After initiation of enteral feeding, there was a significant improvement in glycemic control, with flatter curves and no severe hypoglycemia, presenting a TAR 36%, TIR 63% and TBR 1% (very low 0%).

Conclussion: The treatment of insulinopenic diabetes can be challenging due to the varying amount of insulin needed based on carbohydrate consumption. This can be especially difficult for patients with irregular eating habits, such as those with advanced dementia. In these cases, establishing enteral nutrition through PEG may be an option, as long as the risks and benefits are carefully considered, and it is appropriately indicated. This approach will not only help manage diabetes but also ensure proper nutritional status.