Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 25-year-old woman with type 1 diabetes mellitus is evaluated for recent-onset glycemic fluctuations without symptomatic hypoglycemia. She was diagnosed with diabetes 7 years ago. Her HbA1c levels since diagnosis have ranged from 6.4% to 7.3%, with the most recent value at 7.3%. She reports eating a carbohydrate-consistent diet at each meal, with little variation in her selection of meals or snacks. She started a new job several months ago but continues her daily exercise routine and sleep schedule. She has no other medical problems or symptoms. Her diabetes treatment regimen is insulin glargine once daily and insulin lispro three times daily.
Physical examination findings and vital signs are normal.
Estimate glomerular filtration rate, serum creatinine level, and urine albumin-creatinine ratio are normal. Her blood glucose values from the previous week are shown below.
Blood glucose values:
| Breakfast (mg/dL [mmol/L]) | Lunch (mg/dL [mmol/L]) | Dinner (mg/dL [mmol/L]) | Bedtime (mg/dL [mmol/L]) |
| 124 (6.9) | 190 (10.5) | 109 (6.1) | 210 (11.6) |
| 110 (6.1) | 92 (5.1) | 112 (6.2) | 126 (7.0) |
| 115 (6.4) | 118 (6.5) | 112 (6.2) | 126 (7.0) |
| 117 (6.5) | 127 (7.0) | 204 (11.3) | 110 (6.1) |
| 108 (6.0) | 101 (5.6) | 122 (6.8) | 114 (6.3) |
| 101 (5.6) | 111 (6.2) | 106 (5.9) | 72 (4.0) |
| 126 (7.0) | 187 (10.4) | 102 (5.7) | 196 (10.9) |
Which of the following is the most likely cause of the fluctuating glycemic control?
A. Antibodies to exogenous insulin
B. Gastroparesis
C. Inadequate insulin doses
D. Inappropriate insulin timing
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