Ambulatory Top Ten

Diabetes Clinical Questions

Here are a few common clinical scenarios that you probably encounter several times a week.  Your job now is to say what you would do in these situations and why.  In extreme detail.  Detail the parts of your recommendation which stand on a firm evidence base and the parts which stand on shaky or non-existent evidence.  Secondary sources such as the In the Clinic article attached here, UptoDate, The Hopkins module, and The Cochrane reviews are good places to start your research.  However, your presentation should refer to important primary studies and not just quote recommendations or guidelines. 

1.  You have a patient, a 39 year-old Puerto Rican woman who weighs 200 pounds (BMI of 31) and has a family history of diabetes.  She has tried various diets and exercise regiments but has failed to lose weight.  She wants to know whether she has diabetes or not.  Random afternoon glucose (2 hours after lunch) is 170.  Hemoglobin A1c is 6.9%  What would you recommend?

            -Can hemoglobin A1c be used to “define” diabetes?

            -When should drug therapy for prevention be initiated?

2. The patient is a 52 year-old Guyanese woman who had onset of polyuria and polydypsia  several months ago.  Fasting glucose three days ago at urgent care was 178 mg/dl, Hemoglobin A1c is 8.5%.  Her BMI is 25, she has gained 4 lbs. in the last year.  Her husband also has diabetes; she has been following his diabetic diet with him.  His doctor has him on Actos – the patient tried her husband’s medication twice and says it was “a good pill.”  What would you recommend?

-What evidence is there to support recommendations for a particular diabetic diet?

            -Is there evidence to support one oral therapy over another?

3.  The patient is a 55 year-old mixed race Hispanic man who has had diabetes for eight years.  Initially he responded to recommendations for diet and exercise – he lost five pounds and his glucose normalized.  Then two years later, despite continued efforts, his glucose rose and he began taking metformin.  After increasing the dose to 1000 mg bid, the glucose normalized again.  Then after two years, the glucose began to climb again.  Glyburide 5 mg bid has been added and compliance with diet and exercise continues, but the patient’s last two Hemoglobin A1c’s have been 8.3%.  He has gained four pounds over the last three years.  What changes if any would you recommend in his medical regimen?

–         At what rate do oral therapies fail?  Why do they fail?

–         What evidence is there for combination oral therapy?

–         When should insulin treatment be initiated?

–         When insulin is started, should the oral therapies be continued?

–     Should the patient be referred to a diabetes specialist?

4. The patient is a 56 year-old woman with type 2 diabetes for five years.  She is on metformin 1000 bid and NPH 50 U in the am, 30 U at bedtime.  Morning fasting fingersticks are 55 to 150, bedtime fingersticks are 110 to 200.  Hemoglobin A1c is 8%.  Attempts to increase her am NPH have caused sporadic hypoglycemic episodes, one of which resulted in syncope.  What changes would you recommend?

            – What times of day should fingersticks be performed?

            –  What is the role of regular insulin in a type 2 diabetic?

            –  When should a type 2 diabetic be switched to the newer insulins, glargine and lispro?  Is there evidence of improved control with these?

5.  You have an 82 year-old man as your patient.  He has type 2 diabetes, hypertension, arthritis, and very mild dementia.  He has been injecting insulin twice a day for twenty years.  He has never had an MI, a stroke, PVD, or more than background retinopathy.  Creatinine is 1.5.  BP is 130/70, P 68. He has loss of protective sensation in his feet in all areas tested.  He does not perform glucometer checks.  His random glucoses are always between 130 and 200 and his Hemoglobin A1c is always between 9% and 10%.   His insurance is medicare alone.  Medications are insulin 25 U in the am, 15 U in the pm, monopril 40, atenolol 50, ASA 81 mg, Zocor 20 mg and acetimenophen prn.  He lives at home with his wife who reminds him to take his medication.  He performs all his own ADLs.  Would you recommend any changes in his regimen?