Case study 1 Mr. K is 74 years old. He is admitted from home with pneumonia and has had type 2 diabetes for five years. Prior to admission to the hospital, Mr. K was taking metformin ER 1,000 mg twice a day (morning and evening) and glipizide ER 10 mg daily. He also has hypertension (taking lisinopril 20 mg daily) and dyslipidemia (taking atorvastatin 40 mg daily). Relevant data are BMI 30.5, BP 136/86, LDL 75 mg/dL, A1C 8.9%. He uses a glucometer to monitor his blood sugar at home, and his average FBS one month prior to hospitalization was 190 mg/dL. Sometimes when he went to watch his grandson’s baseball game, he would get a little lightheaded, especially if he didn’t have time to eat lunch before the game. He would always then get two hotdogs and a milkshake, and the lightheaded feeling would go away. Mr. K has a sedentary lifestyle, and his wife does the grocery shopping and meal preparation. In the hospital, Mr. K’s diabetes was managed with basal and rapid-acting insulin with meals. Upon discharge, he will be advised to resume the metformin ER 1,000 mg twice daily, to stop the glipizide ER 10 mg daily, and to start dulaglutide (Trulicity) 0.75 mg weekly subcutaneous injection. Questions 1. What cues do you see that warrant a change in Mr. K’s medication regimen? 2. Prioritize the teaching needs for Mr. K prior to discharge from the hospital. Case study 2 N. H. is a 64-year-old woman with hypertension, osteoarthritis, and dyslipidemia who was diagnosed with type 2 diabetes (A1C was 8%) a year ago and in addition to her current medications (lisinopril 20 mg daily, acetaminophen 650 mg three times daily, and atorvastatin 20 mg daily), she was started on metformin 1,000 mg twice daily. She was referred to a CDCES and enrolled in a diabetes self-management education group class. She was able to attend the first class but then had car trouble and didn’t make any of the other classes. Over the last year, Mrs. H’s knee arthritis has worsened, and her physical activity decreased significantly, she gained 20 pounds, she stopped the metformin because it caused diarrhea, and she missed a few follow- up appointments with her primary care provider because of transportation issues and competing demands on her time from other medical appointments with her cardiologist. At today’s visit with her primary care provider, notation is made that three months ago she was diagnosed with heart failure with reduced ejection fraction (HFrEF). Today her BMI is 32, BP 140/86, LDL 79 mg/dL, eGFR 50, and A1C 9.2%. Questions 1. What cues do you see that warrant a change in Mrs. H’s diabetes management plan? 2. Prioritize the teaching needs for Mrs. H regarding her diabetes management. Case study 3 P. R. is a 45-year-old coming into the office for follow-up. He continues to complain of acid reflux symptoms at night, which have gotten worse the last few months. He has tried OTC Pepcid with inadequate relief. He works morning shift, so gets up around 6 AM every day. He has coffee and toast for breakfast, lunch at work (often from a food truck or a fast-food restaurant near work), and then an early dinner around 5:00 followed by a snack around 8:30 before going to bed around 10 PM. He notes that he has been eating more in the evening and has gained weight. His PMH includes type 2 diabetes mellitus (for four years), dyslipidemia, hypertension, and recurrent bursitis in the left shoulder. He works in a warehouse and repeatedly has to lift boxes up to 50 pounds. Current medications include OTC Mylanta prn; famotidine 20 mg twice daily; metformin ER 1,000
Responses 1. Cues that the previous home medication regimen for the diabetes is not ideal include: a. A1C above goal. b. Home FBS average above goal of 80 to 130 mg/dL. c. BMI of 30.5. d. Weight gain as a common side effect of glipizide. e. Symptoms of hypoglycemia with missed noontime meal while taking glipizide. f. Diagnoses of hypertension and dyslipidemia, which are additional risk factors for cardiovascular disease and warrant considering using a pharmacologic agent that is cardioprotective. 2. Priority teaching needs prior to discharge include: a. When to take and how to inject dulaglutide. b. Potential side effects of dulaglutide and what to do should they occur. c. Resume the metformin ER twice daily after discharge and stop the glipizide. d. Value of having Mr. K and his wife meet with a certified management plan: a. A1C above goal. b. Diarrhea as side effect of metformin, which prompted discontinuation of a drug without notifying PCP. c. Transportation issues limiting timely access to healthcare. d. Lack of understanding (stopped metformin with no follow-up, didn’t attend diabetes education group class, sedentary lifestyle, increased weight) of the importance of managing glycemia. e. New diagnosis of HFrEF; compelling reason for consideration of taking an SGLT-2. f. BMI of 32; compelling reason to consider medication for diabetes management that will not promote weight gain and may facilitate weight loss. g. Worsening of knee osteoarthritis with subsequent decrease in physical activity. 2. Priority teaching needs regarding diabetes self- management at this office visit: a. Purpose and side effects of new medications prescribed and the importance of reporting any side effect or intolerance to the PCP. b. Relationship of dietary intake to glycemia with referral diabetes care and education specialist (CDCES) for teaching regarding dietary intake and coaching to enhance physical activity. Responses 1. Cues that warrant a change in Mrs. H’s diabetes back to CDCES for nutrition teaching and general diabetes management education with discussion/ information provided related to transportation options so that she can attend. mg twice daily; glipizide 10 mg daily; losartan 50 mg daily; and ibuprofen 800 mg three times daily for bursitis pain. Today his relevant data include BMI 34, BP 152/88, LDL 104 mg/dL, eGFR 88, and A1C 9.4%. Recent FBS have been between 150 and 200. Questions 1. What cues do you see that warrant a change in P. R.’s diabetes management plan? 2. Prioritize the teaching needs for P. R. regarding his diabetes management.
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