Diabetes Case Studies

Diabetes: A Few Case studies
Louis F. Amorosa, MD
Shuchismita Dutta, PhD
Mary Kamienski, PhD APRN
Anupam Ohri, MD
Learning Objectives: Diabetes
• Treatment strategies
• A Few Case Studies
Developed as part of the RCSB Collaborative Curriculum Development Program 2016

Diabetes Symptoms
• Diabetes is a disorder of processing glucose

(and lipids) commonly caused by
• Impaired insulin production (Type 1) OR
• Insulin resistance (Type 2)
• Key Symptoms:
Name What Happens Molecular Reason
Polyuria Increased urination High levels of glucose in blood  filtered
by kidney  removed from body in urine
Polydypsia Increased Increase in water consumption to make up
thirst/drinking water for water loss by frequent urination
Polyphagia Increased hunger Cells are starved of glucose  increased
hunger and feeding
Other Symptoms: Fatigue, Blurred vision, Non healing sores, Unexplained weight loss
Goals for Treating Diabetes
Goal plasma blood glucose ranges

Time of Check For people without diabetes For people with diabetes
Before breakfast (fasting) < 100 mg/dl 70 – 130 mg/dl
Before lunch, supper and
< 110 mg/dl 70 – 130 mg/dl
snack
Two hours after meals < 140 mg/dl < 180 mg/dl
Bedtime < 120 mg/dl 90- 150 mg/dl
A1C (also called
glycosylated hemoglobin
< 6% < 7%
A1c, HbA1c or
glycohemoglobin A1c)
Aggressive Diabetes Treatment Goals: Based on key finding from various population studies
http://www.joslin.org/info/goals_for_blood_glucose_control.html


Treating Type 1 Diabetes
• Need to take insulin shots

• Manage glucose intake (food/nutrition) and
utilizations (exercise)
• Closely monitor glucose levels to avoid
hypoglycemia due to overdose of medication,
inadequate glucose intake or over exercise

Designer Insulins
Insulin Hexamer-
Monomer Equilibrium
• Ultrashort Acting
– Lispro
– Aspart
– Glulisine
• Short Acting
– Regular
– Semi-Lente
• Intermediate Acting http://pdb101.rcsb.org/motm/194
– NPH
– Isophane
– Lente
• Long Acting
– Ultralente
– Glargine
– Degludec
– Detemir
Insulin Degludec

Treating Type 2 Diabetes -1
• Lifestyle Changes to balance energy intake and

storage with insulin supply
– Weight loss will decrease insulin demand
– Exercise will improve insulin sensitivity
• Management of Type2 Diabetes includes
– Healthy eating
• High fiber and low fat diet is recommended
• Low glycemic index foods are helpful
– Regular exercise
• At least 30 minutes of exercise 5 days/week recommended
– Blood glucose monitoring

Treating Type 2 Diabetes -2
• When life style changes are not adequate to

manage blood glucose levels, pharmacological
approaches should be used
• Classes of Non-Insulin drugs help
– Increase insulin secretion
– Increase glucose uptake by cells
– Decrease Glycogenolysis
– Decrease digestion of starch (esp. disaccharides)
– Decrease reuptake of glucose by kidney

Current Treatment Approaches
6. Glucosidase Inhibitors Starch in food
Acarbose, Miglitol Digestion
Undigested/unabsorbed Excess glucose

glucose to Feces
Glucose in Intestine to Urine
7. SGLT-2 Inhibitors
Absorption
Canagliflozin
Low Reabsorption
Blood
Sugar Filtration
Glucose in Blood Glucose in Kidney
2. Sulfonylurea
- - Glipizide
Glucose
uptake
Insulin
Pancreatic High Blood
Glucagon
1. Biguanides
breakdown
Glycogen
Pancreatic Metformin b-cells Sugar

a-cells
3. Thiazolidinediones + 5. GLP-1 Agonists
Rosiglitazone Liraglutide
+ Intestinal
Glucose in Cells cells
Incretins
(GLP-1, GIP) DPP-4
- 4. DPP4
Store as Provide Inhibitors
Glycogen energy Proteolysis Sitagliptin


Case 1: Description
• 55 year old gentleman with past medical

history of Coronary Artery Disease and
Diabetes for last 10 years, on Metformin
1000mg twice daily and Glimepiride 8mg
daily. Patient denies any change in symptoms
recently. Fasting blood glucose 140-160 range
and HgA1c 8%. Patient has a BMI of 31.
• Summarize key points about the case. On the

Glucose Homeostasis concept map, point out
the treatment approaches used in this case.
Case 1: Summary
Background Treatment
• 55 year old male • Metformin 1000mg X2/day
• Diabetes and Coronary • Glimepiride 8mg/day
Artery Disease (CAD)
diagnosed 10 years ago
• FPG: 140-160 mg/dl
• HbA1c: 8%
• BMI: 31
• Symptoms
– Patient denies any recent
change in symptoms

Case 1: Treatment Strategy
Starch in food
Digestion

glucose to Feces
Absorption
Reabsorption
Low
Blood
Sugar Filtration
- -
Glucose
uptake
Insulin
Glucagon
breakdown
Glycogen
Pancreatic b-cells Sugar

a-cells
+
+ Intestinal
Incretins
(GLP-1, GIP) DPP-4
Store as Provide -
Glycogen energy Proteolysis
Case 2: Description
• Patient is a 62 year old gentleman with DM
type2. Patient checks his blood glucose on and
off and reports that his blood glucose is usually in
100s. Patient is currently on Actos ( Pioglitazone)
45mg daily, Metformin 1000mg twice daily and
Glimepiride 4mg daily. He denies polyuria,
polydipsia, feels normal energy levels and has a
BMI of 32 and HbA1c of 9.6%

Glucose Homeostasis concept map, point out the
treatment approaches used in this case.

Case 2: Summary
• 62 year old male • Metformin 1000mg X2/day
• Diagnosed with DM type2 • Actos (Pioglitazone)
• Plasma glucose (patient 45mg/day
reports) ~100mg/dl • Glimepiride 4mg/day
• HbA1c 9.6%
• BMI 32
• Symptoms
– Denies polyuria, polydipsia
– Feels normal energy levels

Starch in food
Digestion

glucose to Feces
Absorption
Reabsorption
Low
Blood
Sugar Filtration
- -
Glucose
uptake
Insulin
Glucagon
breakdown
Glycogen

a-cells
+
+ Intestinal
Incretins
(GLP-1, GIP) DPP-4
Store as Provide -
Case 3: Description
• Patient is a 63 year old lady who was diagnosed
with DM 2 years ago. Patient was started on
Metformin 500mg twice daily. Patient reports
nausea with Metformin. Her blood glucose is
usually in 300s. She sometimes takes up to 5 tabs
of Metformin to get her blood glucose to
improve. She complains of incontinence and has
seen a urologist. She has lost 32 lbs in the last
year and has a HbA1c of 12.5%
Glucose Homeostasis concept map, point out the
treatment approaches used in this case.

Case 3: Summary
• 63 year old female • Metformin 500mg X2 daily
• Diabetes diagnosed 2 yrs – Patient reports nausea with
ago Metformin
• Plasma glucose ~300mg/dl

• HbA1c: 12.5%
• Symptoms:
– incontinence; has seen a
urologist
– lost 32 lbs in the last year

Starch in food
Digestion

glucose to Feces
Absorption
Reabsorption
Low
Blood
Sugar Filtration
- -
Glucose
uptake
Insulin
Glucagon
breakdown
Glycogen

a-cells
+
+ Intestinal
Incretins
(GLP-1, GIP) DPP-4
Store as Provide -
Case 4: Description
• M is a 48 year old female, primarily Spanish

speaking and very little English. She
immigrated from Cuba into Mexico in late
2014- came to US illegally through Texas. She
is of African American/Hispanic descent. She is
legal now and insured. Her husband is also
diabetic. Her Diabetes was diagnosed in April
2015. She has some other morbidities too,
such as Hypertension, Elevated triglycerides,
Depression/anxiety.
Contd.
Case 4: Description contd.
• Here random Glucose finger sticks average

240-250 in office but she reports them to be
180-200 mg/dL at home. Her HbA1c is 9.2 and
blood pressure is elevated at home (170/90)
• She was prescribed Metformin 500 mg (only
once a day since she was concerned about
liver toxicity). This medication was changed to
Janumet 50/500mg of sitagliptin (JANUVIA®)
and metformin tablets - 1 by mouth daily. This
was changed again to Glimepiride 8 mg
because Janumet was too expensive.
Contd.
• Patient is 5’7” tall, 170 lbs and has a BMI of 28.79

• She also takes Atorvastatin 40 mg tabs 1 tab at bedtime
to address her high Triglycerides (293) and Lisinopril
20 mg tabs 1 tab daily – to manage her blood pressure
(123/84)
• Patient has a sedentary life style. She loves to eat rice
and is not very proactive about her nutrition. She is
planning to move to another city and has no clear
plans for continuing her health care there.
• Summarize key points about the case. On the Glucose
Homeostasis concept map, point out the treatment
approaches used in this case.

Case 4: Summary
• 48 year old female • Metformin 500mg X1 daily
• African American/Hispanic; – Patient concerned about liver
Spanish speaking (use toxicity
translators); Immigrant (Cuba • Change to Janumet X1 daily
 Mexico  US via TX); – contains 2 medicines 
Insured; Married (husband sitagliptin:metformin ::
also diabetic) 50:500mg
• Diagnosed with • Changed to Glimepiride 8mg +
– Diabetes (Hb A1C: 9.2; PG ~200 Metformin
mg/dl) – Because Janumet is too
– Hypertension (170/90) expensive
– Elevated triglycerides (293) • Atorvastatin 40mg X1 daily
– Depression/anxiety • Lisinopril 20mg X1 daily
Life style: Sedentary; Loves rice
Moving to another city – health care?

Starch in food
Digestion

glucose to Feces
Absorption
Reabsorption
Low
Blood
Sugar Filtration
- -
Glucose
uptake
Insulin
Glucagon
breakdown
Glycogen

a-cells
+
+ Intestinal
Incretins
(GLP-1, GIP) DPP-4
Store as Provide -
Case 5: Description
• 53 year-old Latino male – speaks English, weighs
210 lbs, has a height 5’10”and a BMI 30.13. He
comes to the clinic from halfway house (being
rehabilitated after release from prison). He
denies alcohol or drug use; is a non-smoker but
has Hepatitis C
• He was taking Metformin and Lantus in prison
but has had no medication since his release. He
was prescribed Metformin 1000 mg in am and
500 mg in pm; Lantus 90 unit sc daily; Lisinopril
20 mg daily; Atorvastatin 40 mg daily, Amlodipine
10 mg daily
Contd.
• In a recent visit to the clinic, his BP is now

133/83; Weight 190 lbs. His random blood
glucose test is still at 214 mg/dL and has
been discharged from the halfway house. He
now lives in a shelter and receives food
stamps. He was counseled about nutritional
habits and prescribed a glucometer
Case 5: Summary
• 53 year-old Latino male – • Metformin 1000mg in am
speaks English and 500mg in pm
• Came from half-way-house
• Lantus 90 unit
• Denies alcohol or drug use
subcutaneous daily
• non-smoker
• Physical: • Lisinopril 20mg X1 daily
– Weight 210 lbs Height 5’10” • Atorvastatin 40mg X1 daily
– BMI 30.13
• Amlodipine 10mg X1 daily
– Triglycerides 298 Calcium channel blocker
– HbA1C 9.6 for blood pressure
– Fingerstick at visit 304 mg/dl

Starch in food
Digestion

glucose to Feces
Absorption
Reabsorption
Low
Blood
Sugar Filtration
- -
Glucose
uptake
Insulin
Glucagon
breakdown
Glycogen

a-cells
+
+ Intestinal
Incretins
(GLP-1, GIP) DPP-4
Store as Provide -
Case 6: Description
• A 75 year-old Latino female- who speaks

Spanish and very little English has been a
patient since 2013. She lives with her english
speaking husband, who takes good care of her.
• She is 122 lbs, 4’10”, has a BMI of 25. She was
diagnosed with Type 2 DM several years ago.
Monitoring glucose randomly shows average
blood glucose levels are at 180 mg/dL. She
and was on Metformin 850 mg twice daily as
well as Lantus 30-35 units daily.
Contd.
• To address her hypertension she takes

Lisinopril 2.5 mg by mouth, and Simvistatin 40
mg daily to address her cholesterol. To
address the pain in legs and feet numbness –
she takes Neurontin 300 mg.
• Patient was advised to keep BS diary and food
diary and check feet daily (e.g. black area on
great toe). Meds changed to Gabapentin 300
mg and Imeprazole 20 QD for stomach pains,
also the Lantus dose was increased to 50 units
SQ HS
Contd.
• Patient had complete loss of sensation in left

foot and almost complete loss of sensation in
right foot
• Patient had Coronary artery bypass graft, but

the HbA1c remained at 20.5% in spite of
increasing the dosages of Metformin and
Lantus. Novolog was added on a sliding scale
and patient (and her husband) received
nutritional counseling at every office visit
Contd.
• Recently it was discovered that the patient

also has Alzheimer’s disease since 2008, which
was not discussed!

the diabetes treatment approaches used in
this case.

Case 6: Summary
• 75 year-old Latino female - • Metformin 850mg X2 daily
speaks Spanish, little English
• Lantus 30-35 units daily
• T2DM Diagnosed many yrs
• Physical: • Novolog (Sliding scale)
– 122 lbs; 4’10” • Lisinopril 2.5mg X1 daily
– BMI 25
• Simvistatin 40mg X1 daily
– Finger stick (PG) 236 mg/dl
– HbA1C 20.5% • Neurontin 300 mg added at
• Complains of HS
– pain in leg
– feet numb

Starch in food
Digestion

glucose to Feces
Absorption
Reabsorption
Low
Blood
Sugar Filtration
- -
Glucose
uptake
Insulin
Glucagon
breakdown
Glycogen

a-cells
+
+ Intestinal
Incretins
(GLP-1, GIP) DPP-4
Store as Provide -
Case 6: Follow Up
• Coronary Artery Bypass Grafting done

• Husband maintains detailed records of plasma
glucose and a food diary – received nutritional
counseling
• Recently revealed that she was diagnosed

with Alzheimer’s disease over 15 years ago
– Added Namenda 5 mg X1 daily – to be reviewed
over time

Case 7: Description
• A 66 year-old Caucasian female, employed

and insured had pre-diabetes. Her BMI was
35.2, weight ~ 300lbs and height 5’. Her
HbA1c never exceeded 6.8. She was on
Metformin 500 mg twice a day. She was also
put on a Sulfonylurea but stopped taking it
because of frequent hypoglycemia
• She got lab work done every 6 months and
received occasional fliers about diabetes from
insurance company.
Contd.
• No one had recommended nutritional

counseling, weight loss or physical activity. But
when both feet became numb. She opted for
bariatric surgery, lost 160 lbs.
• Since the surgery, her blood sugar has been
normal


Case 7: Summary
• 66 year-old Caucasian female • Metformin 500 mg BID
• Insured and employed • Sulfonylurea prescribed but
• Physical: stopped taking because
– BMI 35.2; weight 300 lbs; height frequent hypoglycemia
5’; HbA1C ~ 6.8 incidents
• Both feet are numb
• Had bariatric surgery, lost
• Never received nutritional 160 lbs
counseling or discussed need
– Plasma glucose normal
for physical activity and weight (without any medication)
loss

Starch in food
Digestion

glucose to Feces
Absorption
Reabsorption
Low
Blood
Sugar Filtration
- -
Glucose
uptake
Insulin
Glucagon
breakdown
Glycogen

a-cells
+
+ Intestinal
Incretins
(GLP-1, GIP) DPP-4
Store as Provide -
Case: 7 (Molecular Discussions)
• Inadequate amount of insulin in body

• Drugs increase insulin secretion/function
– Frequent incidents of hypoglycemia
– Insulin deficit was marginal
• Post-Bariatric surgery
– Insulin adequate
– No DM symptoms

Individuals with Diabetes Need …
Activity
Counsellor Registered
Nutritionist
Nurse
Diabetic
Pharmacy
Educator
Advanced
Practice Psychologist
Nursing
Social
Physician Patient workers
Are diabetics getting comprehensive care?

Summary: Diabetes Case Studies

Diabetes Case Studies

Caricato da

Informazioni sul documento

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Diabetes Case Studies

Caricato da

Copyright:

Formati disponibili

Diabetes: A Few Case studies

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

• Diabetes is a disorder of processing glucose

Goal plasma blood glucose ranges

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

• Need to take insulin shots

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

• Lifestyle Changes to balance energy intake and

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

• When life style changes are not adequate to

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

Undigested/unabsorbed Excess glucose

Pancreatic Metformin b-cells Sugar

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

• 55 year old gentleman with past medical

• Summarize key points about the case. On the

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

Undigested/unabsorbed Excess glucose

Pancreatic b-cells Sugar

• Summarize key points about the case. On the

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

Undigested/unabsorbed Excess glucose

Pancreatic b-cells Sugar

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

• Plasma glucose ~300mg/dl

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

Undigested/unabsorbed Excess glucose

Pancreatic b-cells Sugar

• M is a 48 year old female, primarily Spanish

• Here random Glucose finger sticks average

• Patient is 5’7” tall, 170 lbs and has a BMI of 28.79

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

Undigested/unabsorbed Excess glucose

Pancreatic b-cells Sugar

• In a recent visit to the clinic, his BP is now

– Fingerstick at visit 304 mg/dl

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

Undigested/unabsorbed Excess glucose

Pancreatic b-cells Sugar

• A 75 year-old Latino female- who speaks

• To address her hypertension she takes

• Patient had complete loss of sensation in left

• Patient had Coronary artery bypass graft, but

• Recently it was discovered that the patient

• Summarize key points about the case. On the

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

Undigested/unabsorbed Excess glucose

Pancreatic b-cells Sugar

• Coronary Artery Bypass Grafting done

• Recently revealed that she was diagnosed

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

• A 66 year-old Caucasian female, employed

• No one had recommended nutritional

• Summarize key points about the case. On the

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

Developed as part of the RCSB Collaborative Curriculum Development Program 2016

Undigested/unabsorbed Excess glucose

Pancreatic b-cells Sugar