1. 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

2. 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?

3. 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…….

4. 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?

5. 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

6. 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

7. Case #1 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

8. 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

9. 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%)

10. 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?

11. 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

12. 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)

13. 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

14. Case #3 Lipids adequately treated BP 142/86 A1C 9.0 What is appropriate for this patient?

15. Case #3 Metformin, sulfonylurea NOT good choices >80 y/o, or declining renal function Metformin NOT good choice with CHF risk or history

16. Case Study #3 BP abnormal- high risk of recurrent CVA Lipids- Evidence show benefit of treating to age 85, case by case

17. 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

18. 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

19. 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

20. 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

21. Acknowledgements 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

22. 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”

23. 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 http://www.med.und.edu/familymedicine/slidedecks.html iTunes Podcasts (Diabetes) (Free downloads) http://www.med.und.edu/podcasts/ or iTunes>> search UND http://www.med.und.edu/podcasts/ WebMD Page: (under construction) http://www.webmd.com/eric-l-johnson http://www.webmd.com/eric-l-johnson Diabetes e-columns (archived): http://www.diabetesnd.org/?id=73&page=Dr.+Eric+Johnson+Archive