1. NP Rounds December 8th DIABETES MANAGEMENT When you have tried everything?

2.  60 year old aboriginal gentleman  Co managed with physician for 1 st year due to co-morbidities and because we both provide care in the aboriginal community – last year & half I have been his primary care provider  As diabetes educator I do all the insulin starts in our practice and make recommendations for medication changes on all our diabetes patients

3.  Dx diabetes x5 years with underlying CAD, HTN, Dyslipidemia, obesity, GERD, iron deficiency anemia, diverticular disease, hematuria, remote hx asthma, ventral hernia  Initial meds ramipril and pravastatin  Several serious admissions to hospital with chest pain, then escalating blood sugars  Initial diet controlled to metformin  Several admissions to hospital for chest pain then angina

4.  Unable to consider insulin start prior or between initial admissions to hospital  Trial of glicazide with metformin  Diabetes and insulin therapy vs aboriginal belief system  Last admission to hospital blood sugars 30 switched from NPH to pre-mix 30/70 and discharged from hospital day after  Support in a remote community vs discharge planning

5.  Regular follow up complicated by camp job after losing job as D&A counsellor at band office  FMH – children with addictions, 18 y/o daughter pregnant, wife chronic illness, grown up children and grandchildren moving back into home, serious financial issues  Social hx – residential school survivor, recovered alcoholic, serious gambling issue

6.  I started him on NPH insulin at hs then bid with improvement in BG for approx 6 mos  Then managed on metformin and pre-mixed insulin post discharge from hospital for about 8 months – given intensive education, support visits both office/home, seen by diabetes nutritionist  Began to fail on this regime – increased wt gain, increased family and work stressors, return to poor eating habits despite regular follow ups

7.  Having low blood sugars with labile swings and rising blood sugars overall  Unable to get approval for lantus insulin from Health Canada even with special authority  Unable to use other oral drugs i.e. avandia unacceptable potential side effects  Unable to get new drugs and pay for ongoing  Assisted patient to register for fair pharmacare, why when aboriginal  Band getting some benefits privately for some members of the community

8.  Discussed rapid insulin – worry due to in and out of camp  Began to exercise and eat differently at camp with some improvement in blood sugars but worse when at home  Considered lantus again, may actually be safer and less rigid management than pre-mix  Discussed with CDA in CR, also seen by endo  Patient wanting to try lantus and willing to pay

9.  Switch to lantus – with 20% reduction based on N insulin dosage of pre-mix  Really better to go straight across with switch but returning to camp too soon with minimal supervision despite having camp nurse  Regular follow up each time out of camp with initial good improvement once matched N dose with increase by 4 units bid  Stabilized BG for approx 6 mos with a return to rising blood sugars

10. Trying to convince patient we needed to switch insulin based on presentation by Victoria endo  Peaks and troughs with obese type 2  Go back to the basics with NPH and rapid with metformin  Patient resistence +++, less regular follow up as difficult to catch up with patient  2 nd strategy leave lantus add rapid – 3 months to convince

11.  Meds:  metformin 500 mg bid  Ramipril 5 mg od  Pravastatin 40 mg od  Fe glu 300 mg tid  ASA 81 mg od  Insulin Lantus 47 units bid  Humalog 5 units ac meals  Last labs:  A1c 8.0 improved, FBG 7.8, Lipids and renal function okay, no hematuria

12.  Ferritin 4  MCV 78 low  RCDW 18.3  Sat 0.13  TIBC 78  Reticulocyte count normal  OB x 3 normal  Pending colonscopy

13.  Revisit all co-morbidities especially CAD  Wt loss, stress management, residential school support, regime in camp/home  Improvement in BG with humalog, patient added with minimal problems  What to do when BG start rising  Basic pillars of diabetes management  Social situation/stressors  Switch to Humulin N from lantus – covered by benefits

14.  Other insulins  New and old oral drugs  Other options