Transcript Diabetes Case Studies - School of Medicine & Health Sciences

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 condition
Repeat 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
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Lipids:
Cholesterol 210 (<200)
TG’s
185 (<150)
HDL
43 (>50)
LDL
106 (<100)
BP 132/84 (<130/<80)
Diabetes Diagnosis
Category
FPG (mg/dL)
2h 75gOGTT
A1C
Normal
<100
<140
<5.7
140-199
5.7-6.4
>200
>6.5
Prediabetes 100-125
Diabetes
>126**
Or patients with classic hyperglycemic symptoms with plasma glucose >200
** On 2 separate occasions
Diabetes 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
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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
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Medications:
Valsartan/HCT 160/12.5 mg daily
Metformin 1000 mg BID
Atorvastatin 40mg daily
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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 9.0
What 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 abnormalhigh 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,2002
American 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-mail
[email protected]
[email protected]
Phone
701-739-0877 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