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 Lipids: Cholesterol 210 (<200) TG’s 185 (<150) HDL 43 (>50) LDL 106 (<100) BP 132/84 (<130/<80)

6. Diabetes Diagnosis Category FPG (mg/dL) 2h 75gOGTT A1C Normal <100 <140 <5.7 Prediabetes 100-125 140-199 5.7-6.4 Diabetes >126** >200 >6.5 Or patients with classic hyperglycemic symptoms with plasma glucose >200 ** On 2 separate occasions Diabetes Care 34:Supplement 1, 2011

7. 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 (current ADA recommendation)

8. 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

9. 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

10. Case #2 Cholesterol 240 (<200) TG’s 205 (<150) HDL 30 (>40) LDL 129 (<100)

11. Case Study #2 Started Metformin 500 mg BID BP, cholesterol tx with statin and ACEI (need titration), 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%)

12. 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?

13. Case Study #2 Choices include –Adding a basal insulin once daily –Adding any other oral agent –Adding exenatide or liraglutide Any of these are good choices Choice may be made on individual factors Reinforce lifestyle management

14. Case Study #2 Basal insulin –Advantages: Once-daily, comes in pen, easy, likely good results, durable over time –Disadvantages: potential hypoglycemia (not difficult to manage/avoid), weight gain, likely will need combo with another insulin later (not a difficult transition)

15. Case Study #2 Additional oral agent –Advantages: Easy –Disadvantages: eventually lose effectiveness, weight gain (sulfonylureas, TZD’s)

16. Case Study #2 Other injectable (exenatide or liraglutide) –Advantages: Comes in pen, easy, may have weight loss –Disadvantages: eventually lose effectiveness, nausea, vomiting

17. 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

18. Case #3 62 y/o caucasian female dx with DM 2 18 months ago Metformin 1000 mg BID Very active, swims 5 days a week, uses stairmaster

19. Case #3 PMH: breast cancer, hypothyroidism, sleep apnea, dyslipidemia, HTN, microalbuminuria Physical Exam: s/p mastectomies, BP 136/82, P 72, BMI 36

20. Case #3 Medications: Valsartan/HCT 160/12.5 mg daily Metformin 1000 mg BID Atorvastatin 40mg daily Folic acid Calcium + D 3 tablets daily Fluticasone Glucosamine/Chondroitin Pantoprazole 40 mg daily Levothyroid150 mcg daily ASA 81 mg daily

21. Case #3 Lab A1C 6 months ago= 6.7, Now 7.6 CBC, Chem panel unremarkable Lipids, BP treated to target What now?

22. Case #3 Started on Exenatide (Byetta) 5 mcg SQ BID x 30 days, advance to 10 mcg SQ BID (Liraglutide (Victoza) OK too GLP 1 can be used with Glyburide, Metformin, TZD’s, (insulin data) A1C 6 months after start= 6.8

23. Case #4 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)

24. Case #4 Current meds: Metformin 500 mg BID Glyburide 5 mg BID Lisinopril 10mg daily Furosemide 20 mg daily ASA 81 mg daily Simivistatin 20mg daily

25. Case #4 Lipids adequately treated BP 142/86 A1C 9.0 What is appropriate for this patient?

26. Case #4 Metformin, sulfonylurea NOT good choices >80 y/o, or declining renal function Metformin NOT good choice with CHF risk or history

27. Case Study #4 BP abnormal- high risk of recurrent CVA Lipids- Evidence show benefit of treating to age 85, case by case

28. Case #4 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

29. Case Study #4 BP: Increase Lisinopril to 20mg, monitor creatinine and K+ Lipids: Continue present (patient desired Rx) DM: ?

30. Case #4 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

31. Case Study #4 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

32. Elderly Diabetes Patients Sulfonylureas and Metformin generally NOT good choices (renal) TZD’s may be limited by CHF history or risk DPP-IV inhibitors may be good choice -renal dosing,hypoglycemia rare Insulin, particularly basal, may be optimum Johnson EL Brosseau J et al Clinical Diabetes 2008 (26) 4; 152-156 American Medical Directors Association,2002 American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

33. Summary Patients have different requirements depending on diabetes status Many choices exist to individualize treatment Reinforce lifestyle, treat blood sugar, lipids, BP

34. Contact Info/Slide Decks/Media e-mail eric.l.johnson@med.und.edu ejohnson@altru.org Phone 701-739-0877 cell Facebook “North Dakota Diabetes” 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 Medcast 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): Dakota Diabetes Coalition website http://www.diabetesnd.org/ http://www.diabetesnd.org/

35. Acknowledgements William Zaks, M.D., Ph.D., Assistant Medical Director Altru Diabetes Center Grand Forks, ND Slide and Content Review