Case #6

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Chief Complaint

November 21

As you recall, Mrs. White is a 56 year old white female diagnosed with type 2 diabetes. She is attempting to control her blood sugar using lifestyle modification. Her hypertension and hyperlipidemia are being treated with lisinopril 10 mg daily and atorvastatin 10 mg every evening. This case will focus on continued management of her diabetes obesity, HTN, and hyperlipidemia and optimal drug utilization.

Mrs. White has come to the office today for three month follow-up. She reports she has been feeling well. She "tries" to watch her diet. She walks the dog 2-3 times per week, but admits the walks are at a leisurely pace. She has a blood glucose monitor and reports her morning blood sugars have been 160-180, with evening blood sugars of 150-190. Her home systolic blood pressure readings have ranged from the low 130’s to low 140’s with diastolic readings in the low 80’s.

Vitals:

Weight -- 188 lbs.
B/P --136/84
Pulse -- 82 reg.
Resp. -- 16

Physical exam, including inspection of the feet, was normal.

Current medications:

  • lisinopril 10 mg daily
  • atorvastatin 10 mg daily
  • aspirin 81 mg daily
  • multivitamin, 1 tab daily
  • calcium supplement, 500 mg daily

Test Results

Mrs. White had lab work done prior to her visit, and the results were as follows:
plasma glucose (fasting) 170 (70-100)
serum potassium 4.1 (3.5-4.5)
serum creatinine 1.1 (0.8-1.4)
glycosolated hemoglobin 8.9 (4.0-6.0)
cholesterol 223
LDL 128
HDL 40
VLDL 55
triglycerides 274
Chol/HDL 5.6
LDL/HDL 3.2
urinary microalbumin ratio 25 (<30 mcg/mg Cr)
AST 24 (10-35)
ALT 21 (10-35)
alkaline phosphatase 87 (40-130)
  1. In reviewing Mrs. White's medication regimen, her blood pressure and blood sugar readings, and her laboratory data, what changes would you consider?
  2. What classes of oral drugs are available for the treatment of type 2 diabetes mellitus?
  3. Describe the mechanism of action of the classes of drugs in question #14.

Fast Fact

Moderate weight loss, 5-9 kg. (10-20 lbs.) irrespective of starting weight, has been shown to reduce hyperglycemia, dyslipidemia, and hypertension.

 Because of her obesity (BMI approximately 35), Mrs. White is started on metformin 500 mg twice daily with meals. She agrees to see the dietician and to try to exercise in a more beneficial fashion. She will follow-up in two weeks. Until her follow-up appointment, she has agreed to continue monitoring her blood sugars QID and bring the results to her appointment.

December 5

Mrs. White says that she feels well. She has monitored her blood sugar at home; morning blood sugars are running 140's, and evenings 140-150 range. She walks her dog three to four times per week for 30-40 minutes at a "fast pace." She met with the dietician and feels the review has helped her with her diet plans.

Mrs. White presents for her follow-up:

Weight -- 183 lbs.
B/P -- 128/74
Pulse -- 84
Resp. -- 16

Physical exam is unremarkable.
  1. What changes, if any, would you make in Mrs. White's treatment plan?
  2. If Mrs. White’s blood pressure were not well-controlled at this point, what action would be indicated?

Follow-up

You increase Mrs. White’s metformin dose to 750 mg BID. She agrees to continue her diet and exercise program and continue to monitor her blood sugar. She will follow up in two weeks.

December 19

Mrs. White returns for her two week follow-up. She reports feeling well and is looking forward to spending Christmas with her family. She continues her diet and exercise program. She is taking the following medications:

  • metformin 750 mg BID
  • lisinopril 20 mg daily
  • atorvastatin 20 mg each evening
  • aspirin 81 mg daily
  • calcium supplement
  • multivitamin

Her blood sugars are in the 130’s in the morning, and 130-140 in the evening. Her potassium, checked just prior to this visit, is 4.1 and her creatinine is 1.0. Her blood pressure in the office is 128/76.
  1. Would you change anything about Mrs. White’s management at this point?

You start Mrs. White on glyburide 5 mg daily in addition to her metformin. She will continue to follow her diet and exercise program and check her blood sugar.

  1. Are there any additional issues that must be addressed now that Mrs. White has been started on glyburide?

You confirm that Mrs. White knows how to recognize and treat a hypoglycemic episode. She will follow up in one month and have her potassium checked prior to that visit.

January 22

Mrs. White returns for her one month follow-up. Her morning blood sugars have been 100-110 in the morning, 120’s in the evening. She has had no hypoglycemic episodes. Her blood pressure has been in the 120’s over 70’s at home. She continues to watch her diet and walk her dog four times per week, although she is tired of all of the snow and ice.

Mrs. White’s potassium is 4.3. Her blood pressure in the office is 126/74. Physical exam is unremarkable.

She will continue with her current program and follow up in one month, having her lipids, transaminases, potassium, and creatinine checked prior to that visit.

February 25

Mrs. White returns for her follow-up appointment. She is taking the following medications:

  • metformin 750 mg BID
  • glyburide 5 mg daily
  • lisinopril 20 mg daily
  • atorvastatin 20 mg each evening
  • aspirin 81 mg daily
  • calcium supplement
  • multivitamin

Her morning blood sugars have been 100 –110 in the morning, 110-120 in the evening. She occasionally checks her blood sugar after a meal; these values are generally 140-160. She has had no hypoglycemic episodes. Her blood pressure as measured at home remains controlled; your reading in the office is 124/74. Her weight is 170 lbs. Her physical exam is unremarkable.

Recent lab work:

Cholesterol
LDL
HDL
VLDL
triglycerides
Chol/HDL
LDL/HDL		 170
98
42
30
148
4.2
2.3

BUN
Cr
Potassium
HbA1c 		12.0
1.1
4.2
7.2		 (8.0-22.0)
(0.8-1.4)
(3.5-4.5)
(4.0-6.0)
    2. What is your assessment of Mrs. White’s progress?
    3. What type of monitoring and screening should a diabetic patient receive on a routine basis?

Mrs. White agrees to continue her current regimen and follow up in three months. 

May 28 

Mrs. White presents for her three month follow up.  She has been taking her medications as prescribed, checking her blood sugar and blood pressure, watching her diet, and exercising.  She had some problems with “hay fever” earlier in the spring, but now feels well and is happy with her progress.  Her blood sugar and blood pressure (measured at home) remain well-controlled. 

In the office, her weight is 162 lbs.  Her blood pressure is 126/76.  HbA1c is 6.8. 

    2. How often should a foot exam be performed on a diabetic patient, and what should such an exam consist of?

Mrs. White will continue with her current management plan and follow up every three months. 

August 27 

Mrs. White has no complaints other than that it is “just about hot enough” for her. 

  • Weight 156 lbs.
  • BP       124/74
  • HbA1c 6.7

Physical exam is unremarkable. 

Mrs. White will follow up in three months. 

November 23 

Mrs. White feels well.  She has concerns about the leaves in her rain gutters, but none about her health. 

  • Weight 154 lbs
  • BP       126/72 

Physical exam is unremarkable. 

Mrs. White will follow up in three months 

February 24 

  • Weight           164 lbs.
  • BP                 132/76
  • HbA1c            7.6
  • Cholesterol                                182
  • LDL                                          106
  • HDL                                          40
  • VLDL                                        36
  • Triglycerides                              178
  • Potassium                                 4.1
  • Creatinine                                  1.2
  • Glucose (fasting)                        150
  • Urinary microalbumin ratio          35

Physical exam is unremarkable.
    2. What are the recommended guidelines for assessment of proteinuria in diabetic patients?
    3. What conditions can cause transient elevations in microalbumin excretion?
    4. What happened to Mrs. White’s formerly excellent control of her blood sugar, weight, lipids, and blood pressure?

Mrs. White admits that she has “cheated” on her diet a bit and has stopped exercising regularly.  She notes that her dog also seems to have put on a few pounds since they stopped their almost daily walks.  She says that she still checks her blood sugar, though not as often, since she finds the high readings discouraging.  She insists that she takes all of her medication “like clockwork”.
    2. What changes would you like to make in Mrs. White’s management?

Mrs. White tells you that her sister in law developed diabetes in her late 50’s. She was initially treated with “pills”, but now uses insulin. Mrs. White asks whether she will have to use insulin as well.
    2. How will you answer her?

You explain the way in which insulin might fit into Mrs. White’s care and emphasize the importance of continuing therapeutic lifestyle changes.  You point out that Mrs. White’s recent problems with her glycemic control appear to be related to her non-adherence to her diet and exercise regimen.  Mrs. White says that she wants to avoid taking any additional medication if this is possible.  She would like to try going back to the more stringent program that she had been following in the past; if that doesn’t work, she would be willing to consider adjustments to her medications.  She will follow her diet, exercise regularly, and follow up in three months.   

May 19 

Mrs. White returns for her three month follow up.  She has been following her diet and walking her dog briskly 4-5 times per week.  She feels that both she and the dog are healthier and more energized, and neither have been troubled by fleas.  Her morning blood sugars have been 100-120, while her evening levels have been 110-120.  Her blood pressures at home have been 120’s/ 70’s.  She is taking the following medications:

  • metformin 750 mg BID
  • glyburide 5 mg daily
  • lisinopril 20 mg daily
  • atorvastatin 20 mg each evening
  • aspirin 81 mg daily
  • calcium supplement
  • multivitamin
  • Weight                         156 lbs.
  • BP                               128/76
  • HbA1c                          6.9
  • Urinary microalbumin ratio 28

Physical exam is unremarkable. 

You congratulate Mrs. White on her success.  She will follow up every three months.

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