Diabetes: A Few Case studies

Diabetes: A Few Case studies
Louis F. Amorosa, MD Shuchismita Dutta, PhD Mary Kamienski, PhD APRN Anupam Ohri, MD

Learning Objectives: Diabetes
Treatment strategies A Few Case Studies

Diabetes Symptoms Diabetes is a disorder of processing glucose (and lipids) commonly caused by Impaired insulin production (Type 1) OR Insulin resistance (Type 2) Key Symptoms: Name What Happens Molecular Reason Polyuria Increased urination High levels of glucose in blood  filtered by kidney  removed from body in urine Polydypsia Increased thirst/drinking water Increase in water consumption to make up for water loss by frequent urination Polyphagia Increased hunger Cells are starved of glucose  increased hunger and feeding Other Symptoms: Fatigue, Blurred vision, Non healing sores, Unexplained weight loss

Goals for Treating Diabetes
Goal plasma blood glucose ranges Time of Check For people without diabetes For people with diabetes Before breakfast (fasting) < 100 mg/dl 70 – 130 mg/dl Before lunch, supper and snack < 110 mg/dl Two hours after meals < 140 mg/dl < 180 mg/dl Bedtime < 120 mg/dl mg/dl A1C (also called glycosylated hemoglobin A1c, HbA1c or glycohemoglobin A1c) < 6% < 7% Aggressive Diabetes Treatment Goals: Based on key finding from various population studies

Treating Type 1 Diabetes
Need to take insulin shots Manage glucose intake (food/nutrition) and utilizations (exercise) Closely monitor glucose levels to avoid hypoglycemia due to overdose of medication, inadequate glucose intake or over exercise

Designer Insulins Ultrashort Acting Short Acting Intermediate Acting
Insulin Hexamer-Monomer Equilibrium Ultrashort Acting Lispro Aspart Glulisine Short Acting Regular Semi-Lente Intermediate Acting NPH Isophane Lente Long Acting Ultralente Glargine Degludec Detemir Learn more about Designer Insulins at The main principle in designing the different types of insulin is to shift the equilibrium of the hexamer (storage form) and monomer (active form) of insulin. Insulin Degludec

Treating Type 2 Diabetes -1
Lifestyle Changes to balance energy intake and storage with insulin supply Weight loss will decrease insulin demand Exercise will improve insulin sensitivity Management of Type2 Diabetes includes Healthy eating High fiber and low fat diet is recommended Low glycemic index foods are helpful Regular exercise At least 30 minutes of exercise 5 days/week recommended Blood glucose monitoring

Treating Type 2 Diabetes -2
When life style changes are not adequate to manage blood glucose levels, pharmacological approaches should be used Classes of Non-Insulin drugs help Increase insulin secretion Increase glucose uptake by cells Decrease Glycogenolysis Decrease digestion of starch (esp. disaccharides) Decrease reuptake of glucose by kidney

Current Treatment Approaches
Starch in food 6. Glucosidase Inhibitors Acarbose, Miglitol Digestion Excess glucose to Urine Undigested/unabsorbed glucose to Feces Glucose in Intestine Absorption 7. SGLT-2 Inhibitors Canagliflozin Low Blood Sugar Reabsorption Filtration Glucose in Blood Glucose in Kidney 2. Sulfonylurea Glipizide - - Glucose uptake Insulin Glucagon Glycogen breakdown 1. Biguanides Metformin Pancreatic b-cells High Blood Sugar Pancreatic a-cells + 3. Thiazolidinediones Rosiglitazone 5. GLP-1 Agonists Liraglutide + Intestinal cells Glucose in Cells Incretins (GLP-1, GIP) DPP-4 Store as Glycogen Provide energy - 4. DPP4 Inhibitors Sitagliptin Proteolysis Developed as part of the RCSB Collaborative Curriculum Development Program 2016

Case 1: Description 55 year old gentleman with past medical history of Coronary Artery Disease and Diabetes for last 10 years, on Metformin 1000mg twice daily and Glimepiride 8mg daily. Patient denies any change in symptoms recently. Fasting blood glucose range and HgA1c 8%. Patient has a BMI of 31. Summarize key points about the case. On the Glucose Homeostasis concept map, point out the treatment approaches used in this case.

Case 1: Summary Background Treatment 55 year old male
Diabetes and Coronary Artery Disease (CAD) diagnosed 10 years ago FPG: mg/dl HbA1c: 8% BMI: 31 Symptoms Patient denies any recent change in symptoms Metformin 1000mg X2/day Glimepiride 8mg/day

Case 1: Treatment Strategy
Starch in food Digestion Excess glucose to Urine Undigested/unabsorbed glucose to Feces Glucose in Intestine Absorption Reabsorption Low Blood Sugar Filtration Glucose in Blood Glucose in Kidney - - Insulin Glucagon Glycogen breakdown Glucose uptake Pancreatic b-cells High Blood Sugar Pancreatic a-cells + For this case, can you place the drugs for treating DM on this concept map and explain how the drug works? + Intestinal cells Glucose in Cells Incretins (GLP-1, GIP) DPP-4 Store as Glycogen Provide energy - Proteolysis Developed as part of the RCSB Collaborative Curriculum Development Program 2016

Case 2: Description Patient is a 62 year old gentleman with DM type2. Patient checks his blood glucose on and off and reports that his blood glucose is usually in 100s. Patient is currently on Actos ( Pioglitazone) 45mg daily, Metformin 1000mg twice daily and Glimepiride 4mg daily. He denies polyuria, polydipsia, feels normal energy levels and has a BMI of 32 and HbA1c of 9.6% Summarize key points about the case. On the Glucose Homeostasis concept map, point out the treatment approaches used in this case.

Case 2: Summary Background Treatment 62 year old male
Diagnosed with DM type2 Plasma glucose (patient reports) ~100mg/dl HbA1c 9.6% BMI 32 Symptoms Denies polyuria, polydipsia Feels normal energy levels Metformin 1000mg X2/day Actos (Pioglitazone) 45mg/day Glimepiride 4mg/day

Case 3: Description Patient is a 63 year old lady who was diagnosed with DM 2 years ago. Patient was started on Metformin 500mg twice daily. Patient reports nausea with Metformin. Her blood glucose is usually in 300s. She sometimes takes up to 5 tabs of Metformin to get her blood glucose to improve. She complains of incontinence and has seen a urologist. She has lost 32 lbs in the last year and has a HbA1c of 12.5% Summarize key points about the case. On the Glucose Homeostasis concept map, point out the treatment approaches used in this case.

Case 3: Summary Background Treatment 63 year old female
Diabetes diagnosed 2 yrs ago Plasma glucose ~300mg/dl HbA1c: 12.5% Symptoms: incontinence; has seen a urologist lost 32 lbs in the last year Metformin 500mg X2 daily Patient reports nausea with Metformin

Case 4: Description M is a 48 year old female, primarily Spanish speaking and very little English. She immigrated from Cuba into Mexico in late came to US illegally through Texas. She is of African American/Hispanic descent. She is legal now and insured. Her husband is also diabetic. Her Diabetes was diagnosed in April She has some other morbidities too, such as Hypertension, Elevated triglycerides, Depression/anxiety. Contd.

Case 4: Description contd.
Here random Glucose finger sticks average in office but she reports them to be mg/dL at home. Her HbA1c is 9.2 and blood pressure is elevated at home (170/90) She was prescribed Metformin 500 mg (only once a day since she was concerned about liver toxicity). This medication was changed to Janumet 50/500mg of sitagliptin (JANUVIA®) and metformin tablets - 1 by mouth daily. This was changed again to Glimepiride 8 mg because Janumet was too expensive. Contd.

Patient is 5’7” tall, 170 lbs and has a BMI of 28.79 She also takes Atorvastatin 40 mg tabs 1 tab at bedtime to address her high Triglycerides (293) and Lisinopril 20 mg tabs 1 tab daily – to manage her blood pressure (123/84) Patient has a sedentary life style. She loves to eat rice and is not very proactive about her nutrition. She is planning to move to another city and has no clear plans for continuing her health care there. Summarize key points about the case. On the Glucose Homeostasis concept map, point out the treatment approaches used in this case.

Case 4: Summary Background Treatment 48 year old female
African American/Hispanic; Spanish speaking (use translators); Immigrant (Cuba  Mexico  US via TX); Insured; Married (husband also diabetic) Diagnosed with Diabetes (Hb A1C: 9.2; PG ~200 mg/dl) Hypertension (170/90) Elevated triglycerides (293) Depression/anxiety Metformin 500mg X1 daily Patient concerned about liver toxicity Change to Janumet X1 daily contains 2 medicines  sitagliptin:metformin :: 50:500mg Changed to Glimepiride 8mg + Metformin Because Janumet is too expensive Atorvastatin 40mg X1 daily Lisinopril 20mg X1 daily Life style: Sedentary; Loves rice Moving to another city – health care?

Case 5: Description 53 year-old Latino male – speaks English, weighs 210 lbs, has a height 5’10”and a BMI He comes to the clinic from halfway house (being rehabilitated after release from prison). He denies alcohol or drug use; is a non-smoker but has Hepatitis C He was taking Metformin and Lantus in prison but has had no medication since his release. He was prescribed Metformin 1000 mg in am and 500 mg in pm; Lantus 90 unit sc daily; Lisinopril 20 mg daily; Atorvastatin 40 mg daily, Amlodipine 10 mg daily Contd.

In a recent visit to the clinic, his BP is now 133/83; Weight 190 lbs. His random blood glucose test is still at 214 mg/dL and has been discharged from the halfway house. He now lives in a shelter and receives food stamps. He was counseled about nutritional habits and prescribed a glucometer Summarize key points about the case. On the Glucose Homeostasis concept map, point out the treatment approaches used in this case.

Case 5: Summary Background Treatment
53 year-old Latino male – speaks English Came from half-way-house Denies alcohol or drug use non-smoker Physical: Weight 210 lbs Height 5’10” BMI 30.13 Triglycerides 298 HbA1C 9.6 Fingerstick at visit 304 mg/dl Metformin 1000mg in am and 500mg in pm Lantus 90 unit subcutaneous daily Lisinopril 20mg X1 daily Atorvastatin 40mg X1 daily Amlodipine 10mg X1 daily Calcium channel blocker for blood pressure

Case 6: Description A 75 year-old Latino female- who speaks Spanish and very little English has been a patient since She lives with her english speaking husband, who takes good care of her. She is 122 lbs, 4’10”, has a BMI of 25. She was diagnosed with Type 2 DM several years ago. Monitoring glucose randomly shows average blood glucose levels are at 180 mg/dL. She and was on Metformin 850 mg twice daily as well as Lantus units daily. Contd.

To address her hypertension she takes Lisinopril 2.5 mg by mouth, and Simvistatin 40 mg daily to address her cholesterol. To address the pain in legs and feet numbness – she takes Neurontin 300 mg. Patient was advised to keep BS diary and food diary and check feet daily (e.g. black area on great toe). Meds changed to Gabapentin 300 mg and Imeprazole 20 QD for stomach pains, also the Lantus dose was increased to 50 units SQ HS Contd.

Patient had complete loss of sensation in left foot and almost complete loss of sensation in right foot Patient had Coronary artery bypass graft, but the HbA1c remained at 20.5% in spite of increasing the dosages of Metformin and Lantus. Novolog was added on a sliding scale and patient (and her husband) received nutritional counseling at every office visit Contd.

Recently it was discovered that the patient also has Alzheimer’s disease since 2008, which was not discussed! Summarize key points about the case. On the Glucose Homeostasis concept map, point out the diabetes treatment approaches used in this case.

Case 6: Summary Background Treatment Metformin 850mg X2 daily
75 year-old Latino female - speaks Spanish, little English T2DM Diagnosed many yrs Physical: 122 lbs; 4’10” BMI 25 Finger stick (PG) 236 mg/dl HbA1C 20.5% Complains of pain in leg feet numb Metformin 850mg X2 daily Lantus units daily Novolog (Sliding scale) Lisinopril 2.5mg X1 daily Simvistatin 40mg X1 daily Neurontin 300 mg added at HS

Coronary Artery Bypass Grafting done
Case 6: Follow Up Coronary Artery Bypass Grafting done Husband maintains detailed records of plasma glucose and a food diary – received nutritional counseling Recently revealed that she was diagnosed with Alzheimer’s disease over 15 years ago Added Namenda 5 mg X1 daily – to be reviewed over time

Case 7: Description A 66 year-old Caucasian female, employed and insured had pre-diabetes. Her BMI was 35.2, weight ~ 300lbs and height 5’. Her HbA1c never exceeded 6.8. She was on Metformin 500 mg twice a day. She was also put on a Sulfonylurea but stopped taking it because of frequent hypoglycemia She got lab work done every 6 months and received occasional fliers about diabetes from insurance company. Contd.

No one had recommended nutritional counseling, weight loss or physical activity. But when both feet became numb. She opted for bariatric surgery, lost 160 lbs. Since the surgery, her blood sugar has been normal Summarize key points about the case. On the Glucose Homeostasis concept map, point out the treatment approaches used in this case.

Case 7: Summary Background Treatment Metformin 500 mg BID
66 year-old Caucasian female Insured and employed Physical: BMI 35.2; weight 300 lbs; height 5’; HbA1C ~ 6.8 Both feet are numb Never received nutritional counseling or discussed need for physical activity and weight loss Metformin 500 mg BID Sulfonylurea prescribed but stopped taking because frequent hypoglycemia incidents Had bariatric surgery, lost 160 lbs Plasma glucose normal (without any medication)

Case: 7 (Molecular Discussions)
Inadequate amount of insulin in body Drugs increase insulin secretion/function Frequent incidents of hypoglycemia Insulin deficit was marginal Post-Bariatric surgery Insulin adequate No DM symptoms

Individuals with Diabetes Need …
Patient Physician Advanced Practice Nursing Pharmacy Nutritionist Activity Counsellor Registered Nurse Diabetic Educator Psychologist Social workers Are diabetics getting comprehensive care?

Summary: Diabetes Case Studies

Diabetes: A Few Case studies

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