Intensification of Diabetic Therapy. Case studies

Transcription

1 Intensification of Diabetic Therapy Case studies

2 Patient #1 1 st visit: 64 year old male, H/O prediabetes, lost weight 280 lbs. to 240 lbs. ER for dental abscess, glucose >300 A1C 11.4%, no diabetic medication, some symptoms of neuropathy, elevated a/c ratio at 65, normal GFR Would you: A) start insulin B) initiate monotherapy C) initiate dual therapy 2nd visit (6 weeks later): Weight unchanged, no meaningful lifestyle change FBG ave. 180, otherwise glucose in 200 s Would you add: A) TZD B) SGLT-2i C) GLP agonist D) DPP-4i E) Insulin F) SU

3 Patient #1 2nd visit (6 weeks later): Was started on metformin monotherapy Weight unchanged, no meaningful lifestyle change FBG ave. 180, otherwise glucose in 200 s Would you add: A) TZD B) SGLT-2i C) GLP agonist D) DPP-4i E) Insulin F) SU

4 Patient #1 3 rd visit (6-8 weeks later), Rx: metformin, 25mg empagliflozin 7 lb. weight loss, no exercise but plans to exercise A1C 7.6%, meter ave. 159 Urine a/c ratio now 49

5 Patient #1 4 th visit (6 months after initial): Walking 2/week, weight not changed A1c 6.9% Would you add a third medication? a) Yes b) No

6 Patient #2 1 st visit in 2006: 61 yo male, Navajo with 10 year h/o Type 2 diabetes RX: pioglitazone 45mg, nateglinide 120 mg before meals, metformin 750 mg twice a day Exercises 5 times per week, has been successful with modest weight to decrease A1C 10.1% Medication options in 2006: Insulins SU and glinides TZDs (Actos, Avandia) GLP (Byetta) Medication options in 2017: More Insulins (long acting analogs including u300 glargine, degludec) SU and glinides TZD (pioglitazone) More GLPs ( albiglutide, dulaglitide, ER exenatide, liraglutide) SGLT-2is (cana, dapa, empa gliflozins) Insulin+GLP (Soliqua, Xultophy) Would you: A) Stop meds and change to basal-bolus insulin B) Continue meds and add basal insulin C) Add SGLT-2i D) Add Insulin+ GLP

7 Patient #2 In 2017: Converted to full insulin 10 years ago, did use Byetta initially but persistent nausea Remains active, no complications A1C for years Rx: glargine insulin 105 units daily, aspart 1 unit/4 grams carb (total daily insulin nearly 200 units/day)

8 Patient #3 69 year old female, Type 2 diabetes has been controlled with metformin for 10 years, A1Cs mid 6% 1 st visit: Began noticing higher glucose levels 2 months ago Weight 92 kg (BMI 38), unchanged from previous FBG 218, A1C 9.3% Would you add: A) Insulin B) SU C) SGLT-2i D) GLP E) DPP-4 F) TZD

9 Patient #3 2 nd visit 5 weeks later: Continued metformin, dapagliflozin added 5mg, then to 10mg Polyuria, polydipsia, visual blurring but no other symptoms Weight down to 88 kg FBG 425 with values up to 500 B OH (beta hydroxybutarate) level 1.6mmol/l This patient requires insulin. Would you: A) Send to ER for possible admission B) Start insulin in your office with close followup

10 Patient #4 1 st visit: 56 year old male with 10 year history of Type 2 diabetes, h/o hypertension Rx Lisinopril 20mg Active lifestyle, muscular Rx: metformin 1000mg BID A1c 7.4% BP 145/96, creat. 1.4 (past 1.8) GFR 57, urine a/c ratio normal Would you add: A) DPP-4i B) SGLT-2i C) GLP D) SU E) TZD

11 Patient #4 2 nd visit 2 months: Linagliptin 5mg added to metformin A1C 7.5% (not improved) Creat. 1.38, GFR 57 Stop DPP-4 (non-responder). Would you add: A) SGLT-2i B) SU C) TZD D) GLP E) Basal insulin

12 Patient #4 Visit 3 (1 month later): Started empagliflozin, continued metformin Complain of postural hypotension, BP 106/70 Glucose ave. 125 Would you: A) Stop empagliflozin, check renal function, select other antidiabetic B) Stop Lisinopril, check renal function, continue empagliflozin

13 Patient #4 Empagliflozin and metformin continued Visit 4, 5 (3 and 6 months later) A1C 6.5, 6.7 BP149/100 resumed Lisinopril at 10mg BP 134/84 Creat. 1.6, GFR 48

14 Patient #5 Initial visit 2006: 56 yo male diagnosed with Type 2 diabetes in mid 40 s Rx: Lantus 50 units, glipizide 10mg bid, metformin 100mg bid A1C 6.8%, peripheral neuropathy present WT. 287lbs (BMI 39) wants help with weight loss Stopped glipizide, added Byetta but didn t tolerate due to nausea Did well with basal insulin, metformin, and lifestyle change until 2015 March 2015: A1C 8.1, weight 272lbs. Studied using Freestyle Libre Pro continuous glucose monitor

15 Patient #5 What would you do to improve post meal control? A) Add prandial insulin B) Continue basal insulin, add GLP (or insulin + GLP) C) Add glinides

16 Patient #5 Visit 3 month late: Stopped glargine, added Soliqua (glargine+ lexisenatide), continued metformin A1C 6.5%, favorable weight loss, tolerated well No insurance coverage for this product Changed to glargine and liraglutide (Victoza) and metformin Next visit A1C 6.0%, Weight 248 ( decrease 24 lbs)