Blood glucose control in adults with type 2 diabetes – case studies
Case study one:
Mrs AB is aged 82 years old and has recently moved to a care home. Ethnicity = caucasian
Past Medical History:
Essential hypertension
Admisison with congestive cardiac failure 2015
CKD 3
Several recent falls
Type 2 diabetes since 2004
Medication:
Metformin 1g BD
Ramipril 10mg OD
Bisoprolol 7.5mg OD
Furosemide 40mg OD
Atorvastatin 40mg OD
Recent blood tests:
eGFR 38 (stable over 3 tests in past 12 months)
HbA1c 79mmol/mol (9.4%)
Total cholesterol 4.2
Recent measurements:
BMI 22kg/m2
BP = 114/62
Questions:
- What individualised HbA1c target would you recommend?
- What are the options for 2nd line blood glucose lowering medication?
- What is the best choice and why?
- What consideration would you give to continuing metformin treatment?
Notes for facilitator – case one (Mrs AB)
Elderly lady with presumed frailty and falls in care home
Stable renal impairment
- Individualised HbA1c target:
Refer group to NICE “patient decision aid” – lots of health problems and age/overall health favours a higher HbA1c target
Standard target would 7 – 7.5% but in this case less than 8.5% seems reasonable
- Options for 2nd line blood glucose lowering medications:
Gliclazide – would be the usual next step
Pioglitazone
DPP4
SGLT – 2
Insulin
- What is best choice and why?
Gliclazide – NO – this lady has a high risk of hypoglycaemia
Pioglitazaone – NO - multiple contraindications – heart failure, risk of fractures (age/sex/care home and immobility/falls) and cauton in elderly
SGLT-2 – NO – age over 75 and eGFR means contraindicated (will not work!) also on furosemide which would increase risk of hypotension
DPP4 – YES – will give 0.5 – 1% HbA1c reduction which will achieve target HbA1c, low hypo risk. At this level of eGFR would need to use a lower dose of sitagliptin 50mg) or use linagliptin (OK with any level of renal impairment)
- Considerations about metformin:
eGFR needs monitorring every 6 months – need to stop metformin if eGFR < 35
At current level of eGFR may consider a lower dose – 500mg BD
Consider whether she is at risk of sudden decline in renal function (for example another emergency admission with heart failure)
Sick day rules for metformin
Metformin does not cause renal damage but patients with low eGFR are at increased risk of fatal lactic acidosis associated with acute illness
Case study two:
Mr CD is 48 years old and works in security. He is a car driver. Ethnicity = Afrocaribbean
Past Medical History:
Essential hypertension
Type 2 diabetes since 2011
Pancreatitis secondary to gallstones 2015
Backround retinopathy but no other known diabetes complications
Medication:
Metformin 1g BD
Gliclazide 160mg BD
Lisinopril 20mg OD
Amlodipine 10mg OD
Atorvastatin 40mg OD
Recent blood tests:
eGFR 58
HbA1c 89mmol/mol (10.5%)
Total cholesterol 3.8mmol/l
ACR 2.1
Recent measurements:
BMI 36kg/m2
BP = 138/79
Questions:
- What individualised HbA1c target would you recommend?
- What are the options to improve glycaemic control?
- What would you suggest to him and why?
Notes for facilitator – case two (Mr CD)
Younger patient in generally good health. First signs of retinopathy. Need to adjust eGFR by 1.21 for ethnicity = 70
- What individualised HbA1c target would you recommend?
Refer to NICE “patient decision aid” – not group 2 driver and aiming for tighter control (young and no known complications)
Target is 7% (trigger for intensification of treatment is 7.5%)
- Options to improve glycaemic control
Lifestyle – advice and has he attended desmond or interested in HELP diabetes?
This is 2nd intensification and patient has HbA1c > 1% over target so insulin is preferred option. However, need to discuss BMI and risk of weight gain. No occupational reasons not to have insulin therapy.
Insulin
GLP-1
DPP4
SGLT-2
Pioglitazone
- What would you suggest and why?
Need to explore pros and cons
Insulin – YES – as above
GLP1 – NO on balance- consider this (although NICE says failed on 3 orals first) however although BMI > 35 he has a h/o pancreatitis (although this was due to gallstones – was gallbladder removed – say not if questioned on this)
DPP4 – won’t achieve target
SGLT-2 – NO on balance – may be worth a try?? Weight loss possible but unlikely to achieve a reduction in HbA1c of 3%
Pioglitazone – NO – probably wont achieve target and weight gain?
If there is time discuss basal insulin start, titration etc