Progression of Diabetes Medication Addition

Transcription

1 Progression of Diabetes Medication Addition By Jacqueline L. Cook, FNP, CDE, CCD Case Study: A 56 year old male, Fred, comes into your office for a routine check up. He states he just isn t feeling well. He has been more tired. Seems to be hot all the time. He has gained some weight. He has been really hungry lately. He has not been nauseated. No vomiting. He has had a mild headache. He denies chest pain or shortness of breath. He seems to ache more. Standing on the cement is starting to get to him. His vision has been a little blurry lately, sometimes people seem to have Halos around them. He just wants to make sure everything is okay. Past Medical/Surgical History High blood pressure. He is on benazepril He denies any surgeries in the past He denies any hospitalizations in the past Social History Works in a manufacturing plant. He is a foreman so he works in the factory, but also has an office. He doesn t smoke, he works in a smoke free workplace, but he does chew tobacco. About a can/day He drinks a couple of beers on Saturday during his poker games with the guys He is married and has 3 children, all of who are out of the house on their own He likes to hunt, fish and camp. Family History Physical Exam Dad had an MI Mother, grandmother and grandfather had diabetes. Thyroid issues run in the family Denies any family history of cancer 134/82, 72, 16, 71 inches. Weight 282 pounds BMI

2 Normocephalic, PERL, He does have a few Xanthomas noted around his eyes Thyroid symmetrical, non-tender, neck supple without lymphadenopathy Equal rise and fall of chest. Lungs CTA bilaterally HRR, no murmurs, pedal pulses regular Abdomen is obese Ambulates without difficulty CMP Na 138 K 4.1 CL 100 Glucose 240 BUN 27 Creat 1.3 GFR 58 Ca 9.4 ALT/AST 37/23 Routine Blood Work: CBC H/H 14.5/44.3 TSH 1.5 A1c 10.2 Call him back and tell him he has diabetes, and you need to talk to him in the office about this diagnosis What do you do when he returns? 1. Discuss Lifestyle changes only 2. Start metformin 3. Do nothing and bring him back in 3 months and see how he is doing 4. Start insulin 1 month later Blood sugars are 200 range. No hypoglycemia He is walking 20 minutes a day at lunch Trying to cut back on his portions He is feeling a little better but he has terrible urgency of defecation. Just hits him all of a sudden He has noticed when he eats cornbread and beans his blood sugars really go up. Sometimes over 300 2

3 Log review Checking 1 time daily Fasting 180 Later in the day 200 Medication Drop in A1c Sulfonylurea GLP Thiazolidinedione SGLT2 inhibitor DDP uptodate, Inc. Summary of glucose lowering interventions. 3 month check-up When do you bring him back? Exercising 20 minutes a day Watching his portions Cut out all sweet tea Tolerating the GLP-1 well A1c 6.5 Weight is down 20# Feels good Sleeping well What would you do if he came back and his A1c was 8.2 on metformin and GLP-1? 3

4 Case Study #2 A 60 year old male, Richard, comes into your office. He is here for a routine check-up for a work-place wellness program. He has no complaints. Feels fine. Sometimes his vision is a bit blurry, but overall he is doing well. Medications Past Medical/Surgical History Metformin 1000 mg BID Glimepiride 8 mg Benazepril Pravastatin Cyclobenzaprine prn Ibuprofen prn Type 2 diabetes for 20 years Hypertension Hyperlipidemia He had a vasectomy but no other surgeries Was hospitalized with surgery, but no other hospitalizations Social History Works as an accountant. Busiest from January to April in a manufacturing plant He doesn t smoke or chew tobacco He is married and has 2 children and 3 grandchildren He likes to work in the yard, watch football on TV. He is active in his local church Family History Dad had an MI Mother, grandmother and grandfather had diabetes. Thyroid issues run in the family Denies any family history of cancer 4

5 Physical Exam 134/82, 72, 16, 68 inches. Weight 250 pounds BMI 38.0 Normocephalic, PERL, He does have a few Xanthomas noted around his eyes Thyroid symmetrical, non-tender, neck supple without lymphadenopathy Equal rise and fall of chest. Lungs CTA bilaterally HRR, no murmurs, pedal pulses regular Abdomen is obese Ambulates without difficulty CMP Na 138 K 4.1 CL 100 Glucose 240 BUN 27 Creat 1.5 GFR 45 Ca 9.4 ALT/AST 37/23 Routine Blood Work: CBC H/H 14.5/44.3 TSH 1.5 A1c 10.2 LDL 100 TGS 180 What do you do? 5

6 Which Insulin do I use? References: Levemir Lantus Toujeo Tresiba NPH Regular U-500 insulin 2018 Uptodate, Inc. AACE/ACE guidelines for diabetes management American Diabetes Association 6