A special case?

There's this young man, 25, diagnosed with type 1 diabetes 10 days ago, presented with severe ketoacidosis. He was underweight, his BMI was around 16, you could see his bones under his skin. A striking exofthalmia.The ketoacidosis was treated, the first 2 days he couldn't eat much because of the nausea, after that his appetite came back, his hunger has no limits, he often hides and eats so that nurses don't see him.
We increased the insulin dose to cover a higher amount of carbs, given the fact he's malnourished, but we reached almost 3 units/kg body weight and still his glycemias are around 300. Education in his case is hard to do, because of his very low IQ.This boy comes from a very poor family, has a history of child abuse, and a mental retardation. TSH level is very low, we are waiting for the FT4, FT3 results, but he probably has also an autoimmune thyroiditis.

Q: what would you do ?

his body weight increased with 6 kgs, mainly because of rehydration
The doses today were: Apidra 40 UI in the morning, 34 at noon, 40 at dinner
Lantus 44 UI bedtime.
Insulin pump is not an option, he doesn't even have an id card, not to mention insurance.
I really need good suggestions. ty

Even with the low IQ, education is important for everyone who has diabetes. The level of it and approach to it must be different though, Maybe focus on a little a day, and make it more hands on?

Lantus and Apidra are good insulins, and very appropriate in this case. Usually people who take Lantus twice a day instead of once a day have better control, and can often take less insulin overall, since you don't rely on a pooling effect so much to get the extended action. This also allows you to adjust the dose for his basal needs at that time of day.

Apidra has the benefit of being very fast acting. Rather than set dosing, I prefer to use rapid acting insulins to carb count and adjust for what is being eaten. Apidra can be given after the meal, allowing him to eat until he is full, then get his shot. This might deter the sneaking of food. You can even allow for shots to cover snacks in between meals.

Basic nutrition information I would include might be what foods are carbs, and what are not. You can teach him "free foods" and meats to fill up on as well, to prevent him from filling up on just carbs and needing more and more food.

I'm not sure how low is IQ is, or if he will even be living independently, but other necessary information to include is injection technique and glucose testing. Apidra and Lantus both use the Opticlik pen in the US. It comes in two different colors, so make sure he keeps the color pen consistent with the type of insulin to avoid confusion. Also, a glucose meter that doesn't require coding, such as the ones made by Bayer and the Compact ones from Accu-chek may be preferable.

If feasible, counseling would be advisable. Being diagnosed with a major chronic illness is hard on anyone, but counseling would be especially advisable with the abuse history.

Another important thing is helping this man see if he qualifies for low income insurance programs.

Finally, obviously the thyroid needs to be treated properly. Education may be easier once the thyroid condition and the diabetes is better controlled.

Glad to hear he's doing better. Did they run a c-peptide? That could tell you if oral meds were any option as well. Report It

he is just so ravished with hungay. They is likely a way to explain all of this to him in his own terms. He will need some type of care giver for a while.

If he has a low TSH, don't you think maybe he is having the sustained high BSL's due to hyperthyroidism? That should stabilize when the hyperthyroidism/Graves is treated.

Have you looked for other simple causes, such as infections, or the eating of unaccounted food when staff are not around? Can you keep him on an IV insulin drip with IV nutrients and supplemental drinks such as Ensure, as well as meals to help with re-nourishment?

If there is a history of child abuse and neglect, you can be sure sending him home with these new medical problems will be a horrific death sentence. If the family is not able to care for him due to low IQ also, he needs to be in protective family services custody. There are services in place for mentally impaired adults. There are many nurses who are foster parents. Are you aware of any institutional facilities in the area which will take adults?

This needs to be worked out with family/social services, and he may need a supervised group home. Type 1 very hard to manage even in someone with a HIGH IQ.

P.S. Although I am almost sure his high BG's and large insulin requirements are due to hyperthyroidism, have you checked for actual insulin antibodies?