Diabetes Case Studies

Diabetes Case Studies/Assessment Questions Case 1 Insulin Example 54 yo female, Type 2 DM for 4 years; HgA1c = 8.5 Current medications: Lantus 60 units qHS Regular insulin 10 units with each meal Average blood sugar log: before breakfast 200; after lunch160; before dinner 210; at bedtime 300 Patient complains of hypoglycemia in the mid-afternoon if she skips lunch. 1. Find the basal pattern. Is this stable/flat? If it is not stable what does that indicate? 2. Does the patient’s basal rate explain the hypoglycemia in the mid-afternoon if lunch is skipped? Why? 3. Find the meal coverage pattern. Does blood glucose return to pre-meal levels after each meal? What does this mean? 4. Plan: Oral Hypoglycemic Example Use the above patient with the following meds (no insulin) Current medications: metformin 500mg BID Glyburide 4 mg QD Case 2 67 yo male with a. fib treated successfully with amiodarone -Patient developed pulmonary toxicity. Amiodarone was dc’d; patient was tried on several other medications, but the atrial fibrillation was not controlled Amiodarone was restarted along with prednisone at 20mg QD to lessen the pulmonary SEs. Lifestyle No history of DM Sleeps 8PM – 12AM Reads books the rest of the night Naps in the afternoon Prednisone dose after dinner Blood glucose averages 5PM: 110 7PM: 120 Midnight: 200 8AM: 120 1. Find the pattern 2 hours after prednisone: 7 hours after prednisone: 15 hours after prednisone: 2. What is contributing to the hyperglycemia? 3. How do you fix the problem? What medications match that pattern? Case 3 JM is a 65-year-old man with T2D of 8 years duration. JM is presenting to the pharmacotherapy clinic today following a referral from his primary care provider. JMs PCP has requested a medication evaluation inclusive of a review of his current diabetes care. Upon further discussion with JM, it is determined that he is not opposed to self-injection, but he notes that he experienced frequent hypoglycemic events in the past when he was taking a sulfonylurea and he prefers to take glucose-lowering medications with a low risk of hypoglycemia. JM volunteers that his brother recently died following a myocardial infarction and he is eager to implement changes to minimize his risk of a CV event following his revascularization procedure in early 2019. PMH: T2D, HTN, hypercholesterolemia, h/o CABG in January of 2019, peripheral vascular disease, obesity Current medications: Metformin ER 100mg po BID Linagliptin 5mg po QD Rosuvastatin 20mg po QD Lisinopril 20mg po QD Amlodipine 10mg po QD ASA 81mg po QD Multivitamin po QD SH: lives with his wife of 36 years; works full-time as a software engineer; reports no history of tobacco use; reports consuming alcohol infrequently; when he does drink, he consumes 1-2 alcoholic beverages; reports he could “eat better”; engages in limited physical activity (30 minutes per week of light walking) Lab and vital findings: Weight: 232 lbs; BMI 34kg/m2 BP: 124/84 (average of 3 seated BP readings) Blood glucose: 116mg/dL (fasting) Point-of-care A1C: 8.1% SCr: 1.5mg/dL eGFR: 65ml/min sodium: 139mEq/L potassium: 4.9mEq/L UACR (Urine Albumin-to-Creatinine Ratio): 60mg/g – microalbuminuria LDL: 120mg/dL HDL: 40mg /dL TG: 148mg/dL 1. What interventions could be recommended for JM to mitigate his CV risk according to the current ADA guidelines? 2. Which agents are you adding or discontinuing? 3. Which lifestyle modifications are important for this patient? 4. Which lab values are concerning?