from the desk of the Resident Clinic Director - improving patient care and diabetes

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. Heres an example from today's RCD experience that shows what were up to.

* Please talk to one of us if you're interested in participating in the collaborative!*

Mahdi alerted me to a nursing visit BS OOC - 269 fasting. (This is something you have to address in the few spare minutes you have while RCD between triage, med refills and the occassional fire that erupts in the waiting room. It's fun, actually.) This 66yo Latina lady with her daughter at her side explained that shes NEVER been in control of her diabetes in the 15 yrs shes had it. Her last A1c in 1/07 was 9.8. Her home BG is 200-400. She's been seen only a couple of times here, but already her meds are maxed out: metformin 1000/500/1000 (max), pioglitazone [Actos] 30, glipizide 20 bid (max). So, fair doctor, what do you do?!

Obviously her oral meds arent doing it. Your choices are: increase the actos to 45 (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 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 shes 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 BGs 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. What else? 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 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 cant 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 D/C 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 OOC 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 is, after all, just hormone supplementation) may help patients understand their disease as well as dispell 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, 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 comorbidities 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 moreso 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.

~Casey

cross-posted at:
the Life of KirkHart
Harbor-UCLA Family Medicine blog
Cure This!