Hi all. No, not another anti-Pharm diatribe from me. This one is a clinical diabetes case from the Harbor-UCLA family medicine clinic:
You all know that a few of us family med residents have been involved in the diabetes chronic care collaborative with Drs. Snyder and Cheng. We’ve been trying to provide intensive and attentive care (including testing, treatment, education, and self-management) to our most out-of-control (OOC) diabetic patients. As the Resident Clinic Director (aka “RCD”) for the last month (a required and worthwhile rotation as a 3rd year resident), I’ve been on the front line of patient care at the Family Health Center. Here’s an example from today’s RCD experience that shows what we’re up to.
* Please email me if you’re interested in participating in the chronic care collaborative!*
One of our nurses, Mahdi, alerted me to a patient with fasting blood sugar 256. (This is something you have to address in the few spare minutes you have while RCD between triaging urgent care patient, writing for med refills, and putting out the occasional fire (ie someone with chest pain, residents swamped with clinic, etc) that erupts in the waiting room. It’s fun, actually.) This 66 year old Latina lady with her daughter at her side explained that she’s NEVER been in control of her diabetes in the 15 years she’s had it. Her last Hemoglobin A1c in 1/07 was 9.8% (far above her goal of 7%). Her home sugars run 200 to 400. She’s been seen only a couple of times here, but already her meds are maxed out: metformin 2500mg a day (about max dose), pioglitazone [Actos] 30, glipizide 20 bid (max). So, fair doctor, what do you do?!
Obviously her oral meds aren’t doing it. Your choices are: increase the Actos to 45 a day (max dose)? Start a 4th agent – acarbose, Januvia? All of the above? Start insulin? Take a second: based on what you know about this lady’s diabetic control, how can you best help her?
Well, a little bit more of the story helps. First, she and her daughter are asking for insulin. That doesn’t happen too often (many of our patients fear that insulin causes blindness, amputation, etc – Educate patients, people!), but when someone has a chronic, debilitating condition that isn’t helped with maxed oral meds, she knows that only insulin can help her. Smart lady. Fortunately she’s been given insulin in the past so knows the routine. I start her on NPH 10 units (she’s thin, so 10 is a good start. If she’s obese, I might start 16 units) before bed and counsel her on increasing the dose every 3 days by 2 units if her AM fasting sugars are >130. Both she and her daughter understand, but adjusting insulin like this is tough for newbies; she might need more counseling in the future…
What else do I do? She’s already on 3 orals hypoglycemics. Not having her chart nor knowing her history, I wonder: What else is she taking? carvedilol, lasix, losartan, simvastatin, warfarin – the ingredients of a cardiac patient. Turns out she has CHF and a prosthetic mitral valve. Question: Should she continue Actos? For one, it’s not helping as it is and increasing it to 45mg probably wont help either. Second, many speculate that the heart failure dangers of rosiglitazone [Avandia] may be a class effect, so right now we can’t be sure that pioglitazone [Actos] wont lead to failure also. Especially in this patient who a) isn’t helped with Actos and b) has a history of CHF, we may be doing MORE harm than good giving her Actos even IF she had had A1c improvement. So, I discontinue it.
How about the glipizide? She is on a hefty dose of this sulfonylurea which, on its own and especially when given with insulin, can induce hypoglycemia. So I D/C that too.
I keep her on the metformin at the same dose to continue her peripheral insulin sensitization and inhibit gluconeogenesis, but not after checking her creatinine first to make sure it’s <1.5 and she’s not at risk for lactic acidosis.
Why this email and why this case? Many of our patients are languishing with out-of-control diabetes on the same stale regimen they’ve been on for months or even years. Don’t be afraid to start ramping up therapy more rapidly. We are working on clinic infrastructure improvements to make doing this easier. Secondly, I, for one, will start discussing insulin therapy with all of my diabetics, even those on less-than-max oral therapy. Bringing up insulin early and in the context of physiology (insulin therapy can be simply explained, after all, as just hormone supplementation) may help patients understand their disease as well as dispel some of the myths and fears around insulin use. SubQ injections are, after all, a lot less scary than foot ulcers, amputations and blindness. Finally but most importantly, don’t forget to be a family doctor and see the patient as a whole. What is her understanding of her disease? What does she want from her visit? What other co-morbidities does she have that would change therapy or clinical course? Protocols are tremendously helpful, but they aren’t for everyone. Treat the person, not the disease.
Fortunately she has follow-up here at clinic with her primary doc on July 24, less than a week away, and I’m curious to see how well her sugars are controlled but more so to see how well she and her family take to her new treatment regimen. I think they and I will be happy with the outcome.
the Life of KirkHart