Case Study: Uncontrolled Type 2 Diabetes

By Kevin O. Hwang, MD, MPHReviewed by Clifton Jackness, MD, Attending Physician in Endocrinology, Lenox Hill Hospital and the Mount Sinai Medical Center, New York, NY

A 45-year-old woman with type 2 diabetes arrives for a follow-up visit 1 week after her HbA1c was determined. She has been compliant with metformin 1000 mg twice daily. She reports that her home blood sugar readings have improved slightly but are still high. She admits to a few dietary indiscretions, such as having multiple servings of dessert when going out with friends. For exercise, she has been walking 10 to 15 minutes a day.

She denies polyuria, polydipsia, or blurry vision. The review of systems is unremarkable.

Her medical history is significant for:

Type 2 diabetes, diagnosed 6 months ago when she presented with polyuria, blurry vision, and a random glucose level of 276 mg/dL. Her HbA1c at that time was 8.0%. She was started on metformin 500 mg twice daily, and within 3 months her HbA1c dropped to 7.6%. The metformin was increased to 1000 mg twice daily at that time. She has not had significant hypoglycemic episodes.

Hypertension, treated with lisinopril 40 mg daily. Dyslipidemia, treated with atorvastatin 20 mg daily. Esophageal reflux treated with omeprazole 20 mg daily.

Vital signs are blood pressure 122/76 mm Hg, heart rate 82, respiratory rate 18, temperature 98.1 °F, height 5’5”, weight 196 pounds, and BMI 32.6. She has not gained or lost significant weight since she started treatment for diabetes.

On exam, the lungs are clear to auscultation, the heart has a regular rate and rhythm without murmurs, and the abdomen is nontender. Peripheral pulses are normal, and there is no lower extremity edema. The foot exam shows normal sensation to light touch and no skin or toenail lesions.

Labs:

HbA1c level, determined last week, is 7.3%. Patient’s blood glucose log shows morning fasting glucose ranging from 120 mg/dL to 150 mg/dL,

and postprandial readings at 190 mg/dL to 220 mg/dL.Targets for Diabetes ControlThe American Diabetes Association (ADA) recommends a target HbA1c of less than 7.0%, fasting glucose less than 130 mg/dL, and postprandial glucose less than 180 mg/dL for most patients.1 A more ambitious HbA1c target of 6.0% to 6.5% may be appropriate for patients with a long life expectancy and no cardiovascular disease, provided that this can be achieved without adverse effects, such as severe hypoglycemia. On the other hand, a target HbA1c of 7.5% to 8.0% may be suitable for patients with significant comorbidities, limited life expectancy, and a history of severe hypoglycemia. This goal is also reasonable for patients who have not been able to reach lower

HbA1c levels with multiple diabetes medications and extensive education about diabetes self-management. Given our patient’s overall health profile, her target is an HbA1c level of less than 7.0%, or eventually even 6.0% to 6.5%.AssessmentThe patient’s HbA1c has improved since starting metformin, but is still not at target. Her fasting and postprandial glucose levels are also too high. The underlying causes for hyperglycemia in this patient include dietary factors, inadequate exercise, and obesity. She has no signs or symptoms of an acute illness that could cause hyperglycemia.

The maximum recommended dose of metformin for adults is 2000 to 2500 mg daily, depending on the formulation. Her current total daily dose is 2000 mg, and it is unlikely that her glycemic control will improve significantly just by adding another 500 mg of metformin.

PlanThe patient is referred to a diabetes education and support class. She is briefly counseled on lifestyle changes to improve her diet and increase her physical activity. Diabetic individuals in the intensive lifestyle intervention arm of the Look AHEAD study lost 8.6% of their weight in the first year, with an average reduction in fasting glucose from 152 mg/dL to 130 mg/dL and reduction in HbA1c from 7.3% to 6.6%.2 If a similarly intensive program is available, this patient should be referred to it.If HbA1c is not in the target range on metformin alone (as in this patient), an additional medication would be beneficial. Many options are available, but the ADA recommends choosing one of the following agents in most cases:

Sulfonylurea Thiazolidinedione Glucagon-like peptide (GLP)-1 agonist Dipeptidyl peptidase (DPP)-4 inhibitor Insulin

A number of issues should be considered when choosing between these medication classes, including:

Patient preference for route of administration and other factors Efficacy in reducing HbA1c Potential to cause hypoglycemia Potential to induce weight gain Side effects Cost

Our patient is agreeable to adding another diabetes medication but does not want to use an injectable medication. Since she is obese and has not been losing weight, an important consideration would be to avoid inducing further weight gain. After starting the second medication and working on lifestyle changes, a repeat HbA1c test and follow-up appointment is arranged for 3 months.

Source : Kevin O. Hwang, MD, MPH

Both children and adults like me who live with type 1 diabetes need to be mathematicians, physicians, personal trainers, and dieticians all rolled into one. We need to be constantly factoring and adjusting, making frequent finger sticks to check blood sugars, and giving ourselves multiple daily insulin injections just to stay alive.” 

Mary Tyler Moore

— JDRF International Chairman

Scenario:

"Nick" is a middle-class, 18 year old male of European descent, who is in his first year of studies at York University. He was diagnosed with DM1 at age six and prior to his first semester at York, Nick's parents had Nick maintain strict control over his blood glucose levels, insulin administration, diet, exercise and overall health. He is currently prescribed Humulin R four times a day. When Nick was in high school, several teachers on staff were very supportive of his condition and encouraged Nick to maintain regular eating schedules and inject insulin at regular intervals. For years his diabetes was managed well.

He is living away from his parents and siblings for the first time and lives alone in residence at York. In the past several months Nick has been introduced too manystressors that he is challenged by. He is away from the support of his family, he is responsible for his own meals and insulin management, he is involved in a whole new social group, and his grades don't reflect his capabilities. In addition, Nick is on the rugby team at York and feels peer pressure from his teammates to engage in activities such as chasing girls, binge-drinking, late night fast-food runs, skipping class, pulling all-nighters before exams and extreme training schedules. 

After a night of hard-core partying, Nick was brought to North York General Hospital's Emergency Unit for the second time in his first semester, after falling into hypoglycemic diabetic coma. Upon arrival, Nick had a tachycardia, was diaphoretic, had shallow breathing, and was very pale. Nick's immediate treatment included the administeration of IV glucagon and dextrose. 

It is now three days later and Nick's condition is stable. You are the nurse assigned to Nick. Nick's current vital signs are as follows: BP - 128/78, P - 60 bpm, RR - 16, T - 37.5oC, O2 Sat - 97%. He is alert and oriented to person, place, and time with no subjective complaints of pain. He is neurologically intact. His blood glucose level has stabilized to his pre-university state of 7.8 mmol/L (non-fasting state). He is eating regularly and his fluid intake is equal to his fluid output. Nick does not want his parents to discover that he is in the hospital for the second time in three months and has asked the team not to inform his parents. his parents were threatening to pull him out of school and have him attend a local university so that he can return home.

1. What communication techniques will you use with Nick?

Prior to initiating the nursing process, you consider that research suggests that youth with DM1 have a tenfold increase risk for depression and suicidal ideation (Kanner, Hamrin & Grey, 2003). Psychosocial research involving diabetic teens shows that to communicate effectively, caregivers need to speak to teenagers in a manner that they comprehend; friendly, open-minded, non-threatening, non-lecturing communication. As Nick's nurse, you keep in mind that motivational interviewing, behaviour modification, patient confidentiality, and patient empowerment are vital for an overall positive outcome in treatment. 

2. What are some teaching opportunities that you as a nurse will engage Nick regarding: 

a) Diet and nutrition?

Reinforce the recommended frequency and timing of meal consumption, carbohydrate counting, and the proper ratio of macronutrients (proteins, carbohydrates and lipids). Know that carbohydrate count is the most important factor for DM1 control. Enlist the team dietician for further education.Try to ensure that the dietician has a background with athletes.

Council Nick on the use of alcohol and DM1. That ideally he should refrain from drinking, or drink non-alcholic beer as this has been the behaviour that has pushed him into a critical place more than once.

b) Physical activities session? 

As Nick is already involved in a high-level training program, you can coach Nick and reinforce the importance of monitoring his blood glucose levels prior, during and after exercise. Let him know that many former and current athletes have DM1. For example, Jay Leeuemberg, a professional football player, has spoken about his DM1 and sports and strongly maintains the importance of staying within a healthy BG range. He used to do up to 30 BG checks during one game to maintain proper control for optimal physical and mental performance on the field (University of Colorado).

If blood glucose levels before exercise are below 5.55mmol/L then Nick must consume some the proper ratio of carbohydratest before physical activity to prevent adverse acute reactions. It used to be said that one should not exercise if BG levels were too high, research and experience has shown that this is not the case (University of Colorado). 

c) insulin management?

His old program of BG monitoring and insulin therapy does not suit his new lifestyle. The insulin injection 4 times per day has become very stressful for him to keep up with his busy lifestyle. He is not adhering to the proper schedule so that his insulin dosing is incorrect. He also does not want to monitor his BG levels in front of others and team members. He finds that it might make him look weak

Discuss with the doctor the need for adjustments. For example, reducing the frequency of injections

by administering insulin types and combinations that can safely increase the intervals between insulin injections. This may help him manage his diabetes with the current lifestyle he has. 

Ask Nick if he would feel more comfortable and liberated if he were to use an implanted insulin pump instead. He would then not have to worry about keeping up with his insulin injection times. Also suggest an implanted blood glucose monitor that he can use to control his glycemic level (please refer Treatment section for more detail). 

Remind him that the dosage of insulin he must take with each meal will be adjusted with the new program but re-empahize the importance of the timing of his insulin injections regardless of what method is ultimately decided upon.

d) support system? 

The lifestyle interventions that work best with DM1 patients include frequent contact with health professionals, including telephone calls (Scottish Intercollegiate Guidelines Network, 2010). 

Introduce other support groups for diabetes that may already be existing in his school/residence or in the community that he may not be aware of. For instance, York University has a Diabetes Hope Sports summer camp that Nick could participate in as a potential counsellor. This may address his anxiety and feelings of being an outsider and fear of appearing weak in front of his peers as he will interact with others who face the same struggles.

http://diabeteshopefoundation.com/content/diabetes-summer-sport-camp

3. What tools can we provide the patient with that allows him to maintain full control over their lifestyle and life decisions while guiding his focus towards rational priorities? What would be the overall goals to help Nick move forward? 

Have Nick explore his options and value system. Do an exercise where he reflects on his fall term and lists what his priorities have been to date. This might look like: 1) make new friends 2) socialize with girls & maybe find someone I really like 3) rugby training and practise 4) get good grades or at least pass 5) eat enough food 6) try to manage insulin:food:exercise. 

This is a good time to talk about the low priority of managing his diabetes, the 2 diabetic comas and the idea that staying alive supercedes all of the other priorities. Hopefully he will come to that realization as well. Encourage him that he might need to rearrange things but he might not need to give up the other values that are so important to him. Explain how this might happen. 

You find out that his life has been so contolled prior to University that it felt good for awhile to pretend that he was not different from his friends.

You see how important the sports and social aspect of Unversity and being away from home to him.

He does feel like he is in a spiral that he cannot seem to find a way out of as he does not want to give up anything. 

Opportunities for Nick:

The doctor will discuss the change of his insulin therapy from 4 times per day to either 2 times with a different insulin mix, or ideally, an insulin pump and glucose sensor. The second scenario will provide him with much more freedom and he will be alerted with an alarm when his BG levels are too low. 

Now have him do another priority/value list based on how he wants to move forward so that he can choose his lifestyle AND maintain discipline regarding his health and well-being. Hopefully the DM1 management will be his number one priority in his new value system. 

Source: Mary Tyler Moore

http://diabeteshopefoundation.com/content/diabetes-summer-sport-camp

Clinical Chemistry 3Diabetes type 1 and 2

Case studies

Kenneth B. Monterey

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