Diabetes Case Studies

Eric L. Johnson, M.D. Assistant Professor Department of Family and Community Medicine University of North Dakota School of Medicine And Health Sciences Assistant Medical Director Altru Diabetes Center Grand Forks, ND

Case #1• 42 y/o hispanic female with hx of GDM 6

years ago, term 10lb 5 oz male infant

• Has not been seen for follow-up in 3 years

• FBS done at annual pap/px is 149

Does this patient have type 2 diabetes? What next?

Case #1• Diagnosis of diabetes generally

requires 2 abnormal values

• Patient is at high risk for developing type 2 diabetes

• GDM is a pre-diabetes conditionRepeat FBS 3 days later…….

Case #1

• Repeat FBS 135• Dx: Type 2 diabetes

- FBS >126 on 2 separate occasions

- Could have done an A1C as well• What should be done next for this

patient?

Case #1

• Lipids:

• Cholesterol 210 (<200)

• TG’s 185 (<150)

• HDL 43 (>50)

• LDL 106 (<100)

• BP 132/84 (<130/<80)

Diabetes DiagnosisCategory FPG (mg/dL) 2h 75gOGTT A1C

Normal <100 <140 <5.7

Prediabetes 100-125 140-199 5.7-6.4

Diabetes >126** >200 >6.5Or patients with classic hyperglycemic symptoms with plasma glucose >200

** On 2 separate occasions Diabetes Care 34:Supplement 1, 2011Diabetes Care 34:Supplement 1, 2011

Case #1• Patient had tubal ligation after last

delivery

• Start Metformin 500mg BID, advance to 850-1000 mg BID

• Most newly diagnosed patients should start Metformin (current ADA recommendation)

Case #1

• Diabetes Educator and Dietician

• SMBG• Lifestyle (for now) for BP and lipids

• Make a list of activity, try to start with

10 min/day, work up to 150 min/week

Case #2• 54 y/o white male

• Diagnosed with type 2 diabetes after 2 fasting blood sugars of 154 and 142 and A1C of 6.8

• Pre-existing HTN and dyslipidemia

Case #2

• Cholesterol 240 (<200)

• TG’s 205 (<150)

• HDL 30 (>40)

• LDL 129 (<100)

Case Study #2• Started Metformin 500 mg BID• BP, cholesterol tx with statin and ACEI (need

titration), could add fish oil, on ASA

• Referred to Diabetes Educator and Dietician

• Recommend developing graduated exercise plan (exercise prescription)

• Six months after diagnosis A1C = 6.8% (target <7%)

Case Study #2

• Three years later, patients A1C has risen to 8.4% (target <7%)

• Blood pressure and cholesterol effectively treated (ACEI, HCTZ, Simvistatin, Fish Oil)

• Now what?

Case Study #2

• Choices include– Adding a basal insulin once daily– Adding any other oral agent– Adding exenatide or liraglutide

• Any of these are good choices

• Choice may be made on individual factors

• Reinforce lifestyle management

Case Study #2• Basal insulin

– Advantages: Once-daily, comes in pen, easy, likely good results, durable over time

– Disadvantages: potential hypoglycemia (not difficult to manage/avoid), weight gain, likely will need combo with another insulin later (not a difficult transition)

Case Study #2

• Additional oral agent

–Advantages: Easy

–Disadvantages: eventually lose effectiveness, weight gain (sulfonylureas, TZD’s)

Case Study #2

• Other injectable (exenatide or liraglutide)

–Advantages: Comes in pen, easy, may have weight loss

–Disadvantages: eventually lose effectiveness, nausea, vomiting

Case Study #2 Patient chose additional oral agent

(sitagliptin)

A1C: 6 months later = 7.4% (target <7%) 3 years later = 8.1% (target <7%)

Basal insulin eventually started once daily

Sitagliptin continued

Metformin continued

Case #3

• 62 y/o caucasian female dx with DM 2 18 months ago

• Metformin 1000 mg BID

• Very active, swims 5 days a week, uses stairmaster

Case #3

• PMH: breast cancer, hypothyroidism,

sleep apnea, dyslipidemia, HTN, microalbuminuria

• Physical Exam: s/p mastectomies, BP 136/82, P 72, BMI 36

Case #3• Medications:• Valsartan/HCT 160/12.5 mg daily • Metformin 1000 mg BID• Atorvastatin 40mg daily

• Folic acid• Calcium + D 3 tablets daily• Fluticasone • Glucosamine/Chondroitin• Pantoprazole 40 mg daily • Levothyroid150 mcg daily • ASA 81 mg daily

Case #3

• Lab A1C 6 months ago= 6.7, Now 7.6

CBC, Chem panel unremarkable• Lipids, BP treated to target

• What now?

Case #3• Started on Exenatide (Byetta)

5 mcg SQ BID x 30 days, advance to 10 mcg SQ BID

(Liraglutide (Victoza) OK too• GLP 1 can be used with Glyburide,

Metformin, TZD’s, (insulin data)• A1C 6 months after start= 6.8

Case #4

• 87 y/o white female resident admitted to LTC facility

• Type 2 Diabetes for 20 years

• PMH: HTN, dyslipidemia, mild dementia, hypothyroidism, CVA, CHF

Stage 3 CKD (GFR 37, Creatinine 1.0)

Case #4

Current meds:• Metformin 500 mg BID• Glyburide 5 mg BID• Lisinopril 10mg daily• Furosemide 20 mg daily• ASA 81 mg daily• Simivistatin 20mg daily

Case #4

• Lipids adequately treated

• BP 142/86

• A1C 9.0What is appropriate for this patient?

Case #4

• Metformin, sulfonylurea NOT good choices >80 y/o, or declining renal function

• Metformin NOT good choice with CHF risk or history

Case Study #4

• BP abnormal-

high risk of recurrent CVA

• Lipids- Evidence show benefit of treating to age 85, case by case

Case #4• A1C = 8.0 appropriate for this age group

-less risk of hypoglycemia vs. lower A1C (demented poor at reporting symptoms)

-better alertness than higher A1C

-less urinary incontinence than higher A1C

Case Study #4

• BP: Increase Lisinopril to 20mg, monitor creatinine and K+

• Lipids: Continue present (patient desired Rx)

• DM: ?

Case #4

Choices for Treatment of DM in elderly

• Single injection of basal insulin once daily

OR

• Gliptin (sitagliptin or saxagliptin)

Both have low risk of significant hypoglycemia, can be renally dosed, easy to use, few significant drug interactions

Case Study #4• Started on basal insulin

(detemir or glargine)

8 units with evening meal (patient likely has little beta cell function)

• Metformin stopped• Glyburide stopped• A1C 3 months later 8.2

Elderly Diabetes Patients• Sulfonylureas and Metformin generally NOT

good choices (renal)• TZD’s may be limited by CHF history or risk• DPP-IV inhibitors may be good choice

-renal dosing,hypoglycemia rare• Insulin, particularly basal, may be optimum

Johnson EL Brosseau J et al Clinical Diabetes 2008 (26) 4; 152-156 American Medical Directors Association,2002American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

Summary

• Patients have different requirements depending on diabetes status

• Many choices exist to individualize treatment

• Reinforce lifestyle, treat blood sugar, lipids, BP

Contact Info/Slide Decks/Media

e-maileric.l.johnson@med.und.eduejohnson@altru.org

Phone701-739-0877 cell

Facebook “North Dakota Diabetes”

Slide Decks (Diabetes, Tobacco, other)http://www.med.und.edu/familymedicine/slidedecks.html

iTunes Podcasts (Diabetes) (Free downloads)http://www.med.und.edu/podcasts/ or iTunes>> search UND Medcast

WebMD Page: (under construction)http://www.webmd.com/eric-l-johnson

Diabetes e-columns (archived): Dakota Diabetes Coalition website http://www.diabetesnd.org/

Acknowledgements

• William Zaks, M.D., Ph.D.,

Assistant Medical Director

Altru Diabetes Center

Grand Forks, ND

Slide and Content Review