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
Lipids:
Cholesterol 210 (<200)
TGs 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
Prediabetes 100-125 140-199 5.7-6.4

Diabetes >126** >200 >6.5
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
Cholesterol 240 (<200)
TGs 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, TZDs)

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, TZDs, (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 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)
TZDs 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
eric.l.johnson@med.und.edu
ejohnson@altru.org

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