|Year : 2017 | Volume
| Issue : 3 | Page : 186-188
Clinical case scenarios in the management of diabetes mellitus
Sahana Shetty, Nitin Kapoor, Nihal Thomas
Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Web Publication||7-Aug-2017|
Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore - 632 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shetty S, Kapoor N, Thomas N. Clinical case scenarios in the management of diabetes mellitus. Curr Med Issues 2017;15:186-8
| Introduction|| |
The management of diabetes mellitus involves several therapeutic modalities, and the optimal use of a therapeutic agent depends on the clinician's assessment of the unique clinical situation that an individual presents with. A few case scenarios are presented below, with a discussion of the assessment of the case and suggested advice. These are based on practical scenarios faced by clinicians and can be used in a general practice or specialist setting.
| Case 1|| |
A 46-year-old obese businessman (body mass index - 32 kg/m 2) with essential hypertension and type 2 diabetes mellitus (T2DM) of 8 years' duration presented with poor glycemic control (glycated hemoglobin [HbA1c] - 9.4%). He was on maximal dosage of metformin and sulphonylureas and has been following his diet and exercise schedule very strictly. He is also concerned about his weight and wants advice on which class of oral antidiabetic drug would be best suited in his case that may provide efficacious glycemic control, weight loss, and cardiovascular protection. He also wanted to know the side effects of these drugs and what measures he could follow to prevent these adverse events.
In view of the underlying obesity and usage of maximal doses of two classes of oral antidiabetic drugs, this patient will benefit from the addition of sodium glucose co-transporter-2 (SGLT-2) inhibitors, which are not only efficacious in terms of glycemic control and weight loss but will also have additional benefits on blood pressure control and cardiovascular protection. The main adverse effects that this patient should be briefed about would include a possibility of simple urinary tract infections, hypoglycemia, and subtle increases in low-density lipoprotein cholesterol. However, he should also be explained the rare possibility of normoglycemic ketosis, and that if he gets symptoms such as acute-onset dyspnea, nausea, vomiting, and abdominal pain, he should stop taking SGLT2 inhibitors and seek medical attention immediately. To prevent recurrent urinary tract infections, he should be advised to consume adequate fluids, ensure micturition at regular intervals, and to keep good personal hygiene.
| Case 2|| |
A 67-year-old postmenopausal woman was diagnosed to have T2DM 4 years back and is currently on maximal-tolerated dosage of metformin. Her glycemic levels for the past few weeks have not been controlled well with only metformin and needs suggestion for an additional oral antidiabetic agent. The only other comorbidity she had was related to her osteoporosis. She had a fragility fracture recently and is currently on calcium, Vitamin D, and bisphosphonates for prevention of further fractures. She is a lean, frail-looking woman who stays alone in a flat and manages her other daily activities by herself. Which oral antidiabetic agents will best suit her in her current situation?
An elderly woman who stays alone with severe osteoporosis (with fragility fracture) would warrant a drug which does not cause hypoglycemia, is bone friendly, and also weight neutral. Among the available drugs with a low hypoglycemic propensity are metformin, pioglitazone, and SGLT2 inhibitors. Of these, pioglitazone and SGLT2 inhibitors are not ideal for her as they have shown to worsen osteoporosis. Sulphonylureas are very potent and may not be wise to be used in an elderly woman who stays alone given a possible risk of severe hypoglycemia. The best option in her case would be dipeptidyl peptidase-4 (DPP4) inhibitors.
| Case 3|| |
A 55-year-old woman with T2DM of 12 years' duration has recently been diagnosed to have diabetic nephropathy (estimated glomerular filtration rate [GFR] = 50 ml/min; creatinine = 2.1%). She was currently on tablet glimepiride 3 mg/day and will now have to be stopped. Her HbA1c was 6.7% on this tablet. She has mild nonproliferative diabetic retinopathy in both eyes and a history of recurrent urinary tract infections in the past. Which class of oral antidiabetic agent could be considered in her case as she does not want to be started on insulin?
A few oral antidiabetic agents are now available for use in patients with mild-to-moderate renal failure. Among the conventional drugs, repaglinide, gliclazide, and glipizide can be used till a creatinine cutoff up to 2.5 mg%. Among the DPP4 inhibitors, sitagliptin will need a dose reduction based on the GFR. However, others can be used in this patient. SGLT2 inhibitors may be avoided in this patient due to a prior history of recurrent urinary tract infections. However, the patient should be educated about hypoglycemia recognition and management.
| Case 4|| |
A 58-year-old gentleman working as a lawyer, known to have T2DM for 10 years, systemic hypertension, and dyslipidemia, is on tablet metformin 1 g twice daily, tablet glimepiride 4 mg twice daily, tablet sitagliptin 50 mg once daily, tablet telmisartan 40 mg once daily, and tablet atorvastatin 10 mg bedtime. His biochemical evaluation shows fasting plasma glucose of 210 mg/dl, postprandial plasma glucose of 280 mg/dl, and HbA1c of 8.5%. What would you advise?
This individual has uncontrolled T2DM despite being on maximum dose of oral glucose-lowering agents (OGLAs). Augmentation therapy with basal insulin analog such as glargine or detemir can be advised at bedtime with an initial dose of 10 units or 0.2 U/kg in addition to the current OGLAs. He should also be educated on self-monitoring of blood glucose (SMBG) and titration of insulin dose to target the fasting glucose of 80–120 mg/dl and postprandial glucose of 120–140 mg/dl. If on subsequent follow-up, the postprandial sugars show rising trend or if HbA1c >7%, he can be started with premixed insulin at an initiation dose of 0.3 unit/kg/day with the total dose split into 2/3rd before breakfast and 1/3rd before dinner and subsequently titrated based on SMBG.
| Case 5|| |
A 16-year-old boy working as a mason presents with a history of polyuria, polydipsia, and weight loss of 6 kg over 3 months. His biochemical evaluation shows fasting plasma glucose –280 mg/dl, postprandial plasma glucose – 380 mg/dl, HbA1c – 10.5%, and glutamic acid decarboxylase antibody positive. How would you manage?
This young man has type 1 diabetes mellitus and thus requires replacement insulin therapy in the form of basal bolus regimen using short-acting human insulin or insulin analogs as bolus insulin for prandial coverage and long-acting insulin analogs or neutral protamine Hagedorn (NPH) for basal coverage. Based on the economic status of this patient, he can be advised regular insulin with each meal and bedtime NPH. He can be started on 0.5 U/kg/day of total insulin dose which can be split into 40% dose as NPH bedtime and 60% regular insulin for prandial coverage (20% before breakfast, lunch, and dinner). He must be educated on dietary plan, physical activity, SMBG, and hypoglycemic symptoms. The insulin has to be titrated based on SMBG reading every 2–3 days.
| Case 6|| |
A 34-year-old woman presents at 28 weeks' gestation with 75 g oral glucose tolerance test of fasting 118 mg/dl, 1 h glucose - 328 mg/dl, and 2 h glucose - 242 mg/dl. Urine ketones were negative. Clinically, she is obese with signs of insulin resistance in the form of acanthosis nigricans. What would be the management plan?
This woman has overt diabetes in pregnancy and needs strict glycemic control to prevent maternal and fetal complications. She would be advised tablet metformin 500 mg twice daily which can be increased to a maximum of 1 g twice daily and insulin therapy. Insulin therapy in the form of basal bolus would be advised. She can be started with regular insulin 2–4 units before each meal and 4 units NPH bedtime with subsequent adjustment of NPH doses based on fasting glucose (target: 60–90 mg/dl) and regular insulin dose based on 1 h postprandial glucose (target: 100–140 mg/dl).
| Case 7|| |
A 38-year-old woman diagnosed to have type 2 diabetes for 6 years, well controlled on tablet metformin 1 mg twice daily and tablet gliclazide 40 mg twice daily, is admitted with autoimmune hemolytic anemia. She is now started on tablet prednisolone 60 mg/day. Blood glucose monitoring in the ward shows fasting glucose of 360 mg/dl and postprandial glucose of 420 mg/dl, with negative urine ketones. What would you advise?
This woman has corticosteroid-induced worsening of glycemic status. Glycemic target recommended in hospitalized patients is between 140 and 180 mg/dl. In addition to the current oral anti-diabetic agents, this patient needs insulin therapy either in the form of basal bolus insulin regimen which would be ideal or twice daily premixed insulin at an initial dose of 0.3–0.5 U/kg/day with subsequent dose titration based on SMBG. This patient must also be educated on reduction of insulin dose based on SMBG during the period of steroid withdrawal.
| Case 8|| |
A 14-year-old male student with type 1 diabetes of 5 years' duration on three times regular insulin and NPH at bedtime, fairly compliant with treatment, has come for review. His SMBG record shows persistently high fasting and postprandial sugars despite increasing the insulin dose. He complains of hypoglycemic symptoms at midnight 2 weeks earlier which was treated symptomatically, however no reduction in insulin dose was made the next day. For the past 2 weeks, he is symptom free. He is also taking regular insulin just before his meals as he finds it difficult to wait for 30 min in his busy school schedule. How would you manage this patient?
This patient probably has the Somogyi effect due to midnight hypoglycemia and has also developed hypoglycemic unawareness due to recurrent hypoglycemic events. It would be advisable to switch the patient from NPH, which can lead to midnight hypoglycemia during its peak effect, to a long-acting insulin analog with peakless profile such as glargine or detemir. Rapid-acting insulin analogs can be advised as premeal bolus insulin instead of regular insulin as they can be taken 15 min prior or immediately after meals. Dietary counseling and bedtime snack is also an important aspect of management to prevent hypoglycemia in this patient.
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