Diabetes Case Studies
Eric L. Johnson, M.D.
Assistant Professor
Department of Family and Community Medicine
University of North Dakota School of Medicine
And Health Sciences
Assistant Medical Director
Altru Diabetes Center
Grand Forks, ND
Case #1
• 42 y/o hispanic female with hx of GDM 6
years ago, term 10lb 5 oz male infant
• Has not been seen for follow-up in 3
years
• FBS done at annual pap/px is 149
Does this patient have type 2 diabetes?
What next?
Case #1
• Diagnosis of diabetes generally
requires 2 abnormal values
• Patient is at high risk for developing
type 2 diabetes
• GDM is a pre-diabetes condition
Repeat FBS 3 days later…….
Case #1
• Repeat FBS 135
• Dx: Type 2 diabetes
- FBS >126 on 2 separate occasions
- Could have done an A1C as well
• What should be done next for this
patient?
Case #1
• Patient had tubal ligation after last
delivery
• Start Metformin 500mg BID, advance to
850-1000 mg BID
• Most newly diagnosed patients should
start Metformin
Case #1
• Diabetes Educator and Dietician
• SMBG
• Lifestyle (for now) for BP and lipids
• Make a list of activity, try to start with
10 min/day, work up to 150 min/week
Case #1
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•
•
•
2 years later, A1C 8.1
Choices?
Could use almost any other DM med
Patient chose GLP-1
(Byetta or Victoza)
for favorable weight profile
Case #2
• 54 y/o white male
• Diagnosed with type 2 diabetes after
2 fasting blood sugars of 154 and 142
and A1C of 6.8
• Pre-existing HTN and dyslipidemia
Case Study #2
• Started Metformin 500 mg BID
• BP, cholesterol tx with statin and ACEI,
could add fish oil, on ASA
• Referred to Diabetes Educator and
Dietician
• Recommend developing graduated
exercise plan (exercise prescription)
• Six months after diagnosis A1C = 6.8%
(target <7%)
Case Study #2
• Three years later, patients A1C
has risen to 8.4% (target <7%)
• Blood pressure and cholesterol
effectively treated
(ACEI, HCTZ, Simvistatin, Fish Oil)
• Now what?
Case Study #2
 Patient chose additional oral agent
(sitagliptin)
 A1C:
 6 months later = 7.4% (target <7%)
 3 years later = 8.1% (target <7%)
 Basal insulin eventually started once daily
 Sitagliptin continued
 Metformin continued
Case #3
• 87 y/o white female resident admitted to
LTC facility
• Type 2 Diabetes for 20 years
• PMH: HTN, dyslipidemia, mild dementia,
hypothyroidism, CVA,
CHF
Stage 3 CKD (GFR 37, Creatinine 1.0)
Case #3
Current meds:
• Metformin 500 mg BID
• Glyburide 5 mg BID
• Lisinopril 10mg daily
• Furosemide 20 mg daily
• ASA 81 mg daily
• Simivistatin 20mg daily
Case #3
• Lipids adequately treated
• BP 142/86
• A1C 9.0
What is appropriate for this patient?
Case #3
• Metformin, sulfonylurea NOT
good choices >80 y/o, or declining
renal function
• Metformin NOT good choice with
CHF risk or history
Case Study #3
• BP abnormalhigh risk of recurrent CVA
• Lipids- Evidence show benefit of
treating to age 85, case by case
Case #3
• A1C = 8.0 appropriate for this age group
-less risk of hypoglycemia vs. lower A1C
(demented poor at reporting symptoms)
-better alertness than higher A1C
-less urinary incontinence than
higher A1C
Case #3
Choices for Treatment of DM in elderly
• Single injection of basal insulin once daily
OR
• Gliptin (sitagliptin or saxagliptin)
Both have low risk of significant
hypoglycemia, can be renally dosed, easy
to use, few significant drug interactions
Brosseau JD
Johnson EL
Clinical Diabetes Oct 2008
Case Study #3
• Started on basal insulin
(detemir or glargine)
8 units with evening meal
(patient likely has little beta cell function)
• Metformin stopped
• Glyburide stopped
• A1C 3 months later 8.2
Summary
• Implementation of evidenced based
guidelines improves diabetes outcomes
• Guidelines are easily available
• Getting patients to goals is important
• Organized clinical encounters help get
patients to goals
Acknowledgements
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•
•
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North Dakota Department of Health, Karalee Harper
Dakota Diabetes Coalition, Tera Miller
Centers for Disease Control
Office of Continuing Medical Education, UNDSMHS,
Mary Johnson
• Department of Family and Community Medicine,
UNDSMHS, Melissa Gardner
• Brandon Thorvilson, UNDSMHS IT
Slide Decks and iTunes Podcasts
• Podcasts 5 to 10 minute Diabetes Topics
Google
“Dr. Eric Johnson Diabetes Podcasts”
• All slide decks downloadable to view
Google
“Dr. Eric Johnson Diabetes Slide Decks”
Contact Info/Slide Decks/Media
e-mail
eric.l.johnson@med.und.edu
ejohnson@altru.org
Phone
701-739-0877 cell
Slide Decks (Diabetes, Tobacco, other)
http://www.med.und.edu/familymedicine/slidedecks.html
iTunes Podcasts (Diabetes) (Free downloads)
http://www.med.und.edu/podcasts/ or iTunes>> search UND
WebMD Page: (under construction)
http://www.webmd.com/eric-l-johnson
Diabetes e-columns (archived):
http://www.diabetesnd.org/?id=73&page=Dr.+Eric+Johnson+Archive