Overcoming the resistance to use insulin for optimal glycemic control

DM Type 2

42 y/o AA gentleman presenting to clinic for follow up of uncontrolled DM2 diagnosed one year back.

Complains of polyuria , polydipsia and blurry vision since the last visit 2 months back.

Has had a significant weight loss about 36 pounds in 2 months.

Elevated BGT’s constantly ranging 350-450.

No other significant complaints.

Has been compliant with diet and exercise regimen consisting of regular walking.

Last Eye exam Jan’09 revealing no diabetic changes.

Gen: wt loss (36 lbs / 2 months), no fatigue/ tiredness. HEENT: no HA, blurry vision CV: no CP, PND, orthopnea or palpitations Resp: no cough, no SOB. GI: no N & V/ constipation/ diarrhoea/abdo pain GU: polyuria+ , no dysuria Neuro / Ext: no tingling/ numbness/weakness. No

foot ulcer. Skin: no rashes

Diagnosed with DM2 in July’08 when he presented to ER with complaints of

Nausea and Vomiting

Generalized Headache

Generalized Weakness

Seizure episode

Blood Glucose of 1200

Ketones postive

Diagnosed with DKA

After the control of acute episode his blood sugars were fairly well controlled on Lantus, Humalog and oral hypoglycemics until Feb ‘09 when his PCP withheld his insulin and thereafter his Blood sugars have been erratic leading on to poor control of diabetes.

HTN- well controlled on Lisinopril and metoprolol

Dyslipidemia - takes pravastatin

Vitamin D Deficiency

Hypogonadism

Mother and Brother are diabetic.

Both parents have history of heart disease.

Allergies NKDA

Smoker for 9 years ( 1 ppd).

Quit alcohol 8 years ago.

No illicit drug abuse.

Past Surgical History No prior hospitalisations besides the episode of

DKA.

Lantus 50 U BID

Glipizide 5 mg BID

Metformin 1000 mg BID

Lisinopril 20 mg QD

Metoprolol 100 mg BID

Pravastatin 20 mg QD

Vitamin D 1000 U QD

Afebrile

BP 118/86

RR 16/min

PR 72/ min

Weight – 379 lbs

Height – 190 cm

SPOT URINE Glucose – 2000 mg/dl

Ketones - positive

CV : RRR, + S1/S2, no murmurs/ rubs/ gallops.

Respi : Clear to Auscultation.

PA : soft, non-tender, non-distended, + BS.

Neuro : vibration, proprioception and touch sensations intact, reflexes 2+ B/L extremities, motor strength 5/5 throughout.

Extremeties : peripheral pulses palpable, no edema, no ulcer.

July ‘09 Nov ‘08

Total Cholesterol 245 255

HDL Cholesterol 28 25

LDL Cholesterol 116

Triglycerides 752 255

Vitamin D 25-hydroxy 29 17.9

TSH 1.40

Free T4 1.0

24 Hr Urine Protein 350 mg/dl

GFR 120

Microalbumin/ Creatinine Ratio

5.7

Nov’ 08

C-peptide 8.7

GAD antibodies Negative

Free Testosterone 5.27 ng/dl

Worsened drastically after Insulin withhold by the PCP ( Feb ‘09) as oral hypoglycemics alone proved inadequate to maintain blood glucose values in acceptable range.

HBA1C7.7 ( Oct ‘08) 6.0 ( Feb ‘09) 10.6 ( May ‘09)

Lantus Restarted 50 U Bid ( May ‘09)

Add Apidra 25 U Tid with meals alongwith a sliding scale of 4U : 40 mg/dl > 180 mg/dl.

Fish Oil for hypertriglyceridemia.

Vitamin D 1000 U daily.

Once the target glycemic control is achieved, casual attitude on part of physician can jeopardize the diabetes control.

Another issue ( besides non-compliance in patients) that need to be addressed to reiterate aggressive diabetes management goals.

Insulin is the single most important and effective therapy not just in DM1 but also DM2.

Perceived worsening of control.

Perceived personal failure.

Perceived increase in disease severity.

Lack of confidence in their ability.

Injection Anxiety

Perceived lack of benefit.

Remember – glycemic control is the primary goal.

Normalize the use of insulin.

Educate about A1c and prevention.

Keep things flexible and simple

Insulin is an option, not a threat.

Work towards common goals.

July ,09 May ‘09 Nov ‘08

Total Cholesterol 245 255

HDL Cholesterol 28 25

LDL Cholesterol 116

Triglycerides 752 255

Vitamin D 25-hydroxy

29 17.9

TSH 1.40

Free T4 1.0

GFR 120

24 Hr UrineProtein

350 mg/dl

July ’09 May ‘09 Nov ‘08

Microalbumin/ Creatinine Ratio

5.7

C -Peptide 8.7

GAD Antibodies Negative

Free Testosterone 5.27 ng/dl