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.
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?
