Clinical Case: 54 Year-Old Lawyer


#1

Patient Background

54 year old male lawyer has had high blood glucose for over a year, but only now after a random reading exceeds 300 mg/dL on an office visit is he willing to admit that he has diabetes.

He has had a previous heart attack and is taking several cardiovascular and hypertensive medications.

His physical exam today is normal. He has a BMI of 28. He admits to feeling a little tired, recently, and has been getting up at night to urinate at least two to three times per week.

Clinical Profile

Age: 54
Weight: 212 lbs.
Height: 6’ 1"
BMI: 28

Blood Glucose
Last A1C: 10.2%

Fructosamine: 429 mmo/L
(nl <250)

Random: 358 mg/dL

Lipid Profile
Total: 153 mg/dL
LDL: 70 mg/dL
HDL: 41 mg/dL
Triglycerides: 225 mg/dL

Kidney Profile
Creatinine: 0.8 mg/dL

Microalbuminuria:
negative

Liver Function
ALT: normal
AST: normal

Blood Pressure
Normal: 130/90 mmHg

Cardiovascular condition Previous myocardial infarction

Eye Exam
Normal

Foot Exam
Normal pulses and sensation

Lifestyle

Compliance with meal plan?
No diabetes meal plan at this time.

Compliance with exercise plan?
Limited activity and rare exercise.

Current Medications

For blood glucose: none

For other conditions:
HCTZ, 25 mg qd
Metoprolol (Toprol XL), 50 mg qd
Aspirin 81 mg qd
Simvastin (Zocor) 20 mg qd

How would you initially treat this patient?
1)Diet and exercise alone
2)Diet and exercise plus an oral agent
3)Diet and exercise plus an incretin mimetic
4)Diet and exercise plus insulin


#2

4)Diet and exercise plus insulin


#3

Preferred answer: Diet and exercise plus insulin

With a 10.2% A1c, his initial blood glucose control can be characterized as poor (see Table 1). He will need instruction on nutrition and exercise, and would benefit from insulin therapy to quickly establish good blood glucose control.

Table 1: Initial Control

It may be possible to stop the insulin later, but right now it is important to establish good control as rapidly as possible.

When initiating or changing therapy, a major factor in selecting a class of drugs, or a specific medication within a class, is the general level of glycemic control. The A1c level will determine in part which glycemic agent is selected, with consideration given to the more effective glycemia-lowering agent, insulin, for patients with A1c greater than 9.5% or with symptoms secondary to hyperglycemia.

In the setting of severely uncontrolled diabetes with catabolism, defined as fasting plasma glucose levels greater than 250 mg/dL (13.9 mmol/l), random glucose levels consistently greater than 300 mg/dL (16.7 mmol/l), A1c greater than 10%, or the presence of ketonuria, or as symptomatic diabetes with polyuria, polydipsia, and weight loss, insulin therapy in combination with lifestyle intervention is the treatment of choice.1

Although well-educated, the patient has been denying his condition. Significant diabetes education and perhaps psychological counseling may be necessary for him to accept his condition and treat it properly. Most patients, even those who are well-educated, are not knowledgeable enough to deal with their diabetes, so education is generally a cornerstone of diabetes therapy.

Titrating The Insulin Therapy

After a one hour meeting with a diabetes educator, the patient is judged to be capable of self-management. He will receive 10-15 more hours of education.

The A1c goal is set at <7% and/or mean plasma glucose >130 mg/dL, with a fasting blood glucose target <100 mg/dL within four months.

He is asked to write a contract which he then signs.

Patient is started on 10 U of glargine at bedtime using a SoloStar¬ģ pen with 8mm pen needles.

The patient will also follow a carbohydrate counting meal plan and self-monitor his blood glucose 4 times a day. He is taught to use the meter’s 3-day averaging function. The patient also decides to download his meter readings into the software that is available for his blood glucose meter.

The patient is taught to titrate his insulin doses based on his average fasting blood glucose in a 3-day period.

Patient is instructed in writing that every 3 days, if his average fasting blood glucose is >180 mg/dL, he should increase the glargine dose by 3-4 units.

If the average fasting blood glucose is between 130-180 mg/dL, he should increase the glargine dose by 1-2 units.

He will return in five weeks for evaluation. The patient is instructed to call the physician’s office if he experiences fasting blood glucose levels lower than 90 mg/dL, or any allergic reactions to the glargine, as described in the package insert.


#4

Visit 2: Five weeks later

Patient’s A1c has fallen to 9.5%, and he denies any episodes of hypoglycemia.

His weight increased by 2.5 lbs (1.1 Kg), which is expected when initiating insulin therapy.

The fructosamine level has fallen to 317 mmol/L.

He is currently taking 20 U of glargine.

The patient brought in a printout from his blood glucose management software. The blood glucose averages for the past week are shown in the table below:

How might the therapy be adjusted?

1)Continue increasing glargine

2)Initiate rapid-acting mealtime insulin

3)Switch to premixed insulin (combination of intermediate-acting and rapid-acting insulin)

4)Switch to metformin


#5

1)Continue increasing glargine


#6

Preferred answer: Continue increasing glargine

It is appropriate to continue increasing the glargine, as his fasting blood glucose was 184 mg/dL with fairly low variability (standard deviation less than one-third of the mean), with no hypoglycemia. He has not yet reached the fasting blood glucose target of 100 mg/dL.

Although switching to premixed insulin is an option, this patient’s physician wants to continue adjusting the glargine dosage in order to lower the patient’s fasting glucose.

Another consideration is that this patient understands what he is doing‚Ķ so it is easier to ‚Äústay the course‚ÄĚ

A switch to metformin would be premature. The patient needs to achieve better glycemic control for a longer period of time before an oral agent can be considered as a viable option.

The patient is told that if he reaches 30 U of glargine, he may split the dose, talking half in the morning and half in the evening. This is to prevent injection discomfort due to the volume of insulin.

A follow-up visit is scheduled for 4 weeks later.

Visit 3: Four weeks later

The patient’s A1c is down to 8.6%.

He is currently taking 28 U of glargine as a single dose in the evening.

His fructosamine level has fallen to 274 mmol/L.

The patient’s average blood glucose levels in the last week are shown in the table below.

The patient indicates that two of his fasting readings were between 70 and 78 mg/dL. He woke up feeling hungry those two mornings, but had no other complaints.

What therapy adjustment can be made?
1)Continue increasing glargine
2)Initiate rapid-acting mealtime insulin
3)Switch to premixed insulin
4)Switch to metformin


#7

2)Initiate rapid-acting mealtime insulin


#8

Preferred answer: Initiate rapid-acting insulin

Since the patient’s fasting blood glucose is now less than 130 mg/dL, and he has experienced some fasting blood glucose readings between 70-78 mg/dL, an increase of his glargine dose may not be the best course at this time.

Instead, an appropriate choice would be to begin rapid-acting mealtime insulin at the meal preceding his highest blood glucose levels.

His blood glucose is highest before lunch, so 4 units of rapid-acting lispro are prescribed, using a pen with an 8mm pen needle, to be taken before breakfast.

The patient’s blood glucose variability (standard deviation) is low, so he is taught to increase his breakfast lispro by 1 unit every 3 days until his average pre-lunch blood glucose is less than 130 mg/dL.

An option at this time could be a change to premixed insulin, a combination of intermediate-acting and rapid-acting insulins. However, in order to maintain control of his fasting blood glucose, the patient would need two injections: one before breakfast and one before dinner. Taking intermediate insulin at dinnertime increases the risk of nocturnal hypoglycemia, due to the timing of its peak effect. Therefore, the decision is made to add rapid-acting insulin earlier in the day as described above.

Separating the long-acting and rapid-acting injections allows the greatest flexibility with meals, and introduces the patient to the possible use of full basal/bolus insulin therapy at a future date.

A follow-up visit in 4 weeks is scheduled. Note the frequent follow-up visits every 4 to 5 weeks. This allows timely patient-physician interaction and the most rapid attainment of blood glucose targets.

Visit 4: four weeks later

In just three months, the patient’s glycemic control has greatly improved.

He is currently taking 28 U of glargine in the evening, and 7 U of lispro before breakfast.

His A1c has dropped from 10.2% to 7.5%, a reduction of 2.7 percentage points. His overall mean plasma blood glucose fell from 286 mg/dL at visit one, to 164 mg/dL at present. Note that his A1c does not fully reflect the recent decreases in his blood glucose levels.

The patient comments that he is feeling more energetic, and is taking walks with his wife several times per week.

His fructosamine level is 254 mmol/L, which is almost normal.

The patient gained another 1.5 lbs (0.7 Kg).

His blood glucose averages for the past week are shown in the table.

What therapy adjustment can be made now?

1)Increase the glargine dose
2)Add a second dose of rapid-acting mealtime insulin
3)Switch to metformin
4)Add a sulfonylurea


#9

2)Add a second dose of rapid-acting mealtime insulin


#10

Preferred answer: Add a second dose of rapid-acting mealtime insulin

Add a second dose of rapid-acting lispro insulin before dinner in order to lower the bedtime blood glucose levels. This should also help to reduce his fasting blood glucose.

The patient is told to take a small (3 U) dose of lispro before dinner.

Adding a sulfonylurea or metformin to this patient’s regimen is still premature and is not necessary because the patient is complying with his insulin therapy.

A 4-week follow-up visit is scheduled.

Visit 5: Four weeks later

In 4 weeks the patient returns. He is now taking 30 U of glargine as a single evening dose, with no discomfort.

He is taking 7 U of lispro before breakfast, and 4 U of lispro before dinner.

His A1c is now 7.0%.

His blood glucose averages for the past week are shown in the table below. The low standard deviations indicate that he is maintaining his blood glucose within a narrow range.

The patient is congratulated.

With diabetes education, patient empowerment to self-titrate, and patient adherence to a diabetes regimen, this patient was safely brought into excellent glycemic control in 17 weeks, or just over 4 months. He reports that he is feeling better and has more energy. He gained a small amount of weight due to the elimination of glycosuria.

The patient can be scheduled for follow-up visits every 3 to 4 months.

Beta cell function can be restored after treatment of severe hyperglycemia relieves ‚Äėglucotoxicity‚Äô. After achieving good glycemic control, he may respond to an oral agent such as metformin, along with a rapid reduction in the insulin doses.2 It may even be possible to withdraw insulin.

However, type 2 diabetes is a progressive disease, so there is a likelihood that insulin therapy will need to be resumed in the future.


#11

Diet and exercise plus insulin


#12

diet and exercise plus insulin


#13

2 diet and exercise plus an oral agent


#14

Interesting Case Discussion!