IMC Didactic Case on Diabetes Mellitus

Chief Complaint
"I was recently diagnosed with diabetes and would like to have my blood sugar tested. I think
that my blood sugar is running low because I have the shakes and a terrible headache.”
HPI: Sarah Martin is a 43-year-old woman who comes to the pharmacy for a diabetes
education class taught by the pharmacist. She would like for the pharmacist to check her blood
sugar before the class begins. She was diagnosed with diabetes mellitus Type 2 about 6
months ago. She has been attempting to control her disease with diet and exercise but has had
no success. Her physician has recently started her on glyburide 5 mg. She has gained 15 lb
over the past year. She monitors her blood sugar once a day, per her physician, with a range of
215–260 mg/dL. Her fasting blood sugars average 170 mg/dL. She took her glyburide this
morning but didn’t have time to eat breakfast.
PMH: Type 2 DM x 6 months
HTN x 15 years
Asthma x 20 years
Dyslipidemia x 10 years
Morbid obesity x 15 years
FH: Father has history of HTN. Mother has a history of dyslipidemia. Brother has DM
secondary to alcoholism.
SH: Has been married for 21 years. She has two children who are teenagers. She works in a
floral shop making deliveries. She does have limited medical/prescription insurance through her
husband’s factory job. She smokes ½ pack per day of cigarettes (down from 1 pack per day 6
months ago) and drinks alcohol occasionally (five beers/wine per week).
Meds:
Glyburide 5 mg po BID
Lisinopril 20 mg po once daily
Advair 250mg/50mg 1 puff BID
Fluoxetine 20 mg po Q AM
EC ASA 81 mg po once daily
Pravastatin 40 mg po once daily
All: Morphine—hives
ROS: Complains of nocturia, polyuria, and polydipsia on a daily basis. Denies nausea,
constipation, diarrhea, signs or symptoms of hypoglycemia, paresthesias, and dyspnea.
Physical Examination: severely obese, Caucasian woman in NAD, R and L fundus exam
without retinopathy. Lungs- clear breath sounds, no wheezing or cyanosis. Cardiac- RRR, no
MRG. Extremities- femorals, popliteals, and right dorsalis pedis pulses 2+ throughout; left
dorsalis pedis 3+; feet show mild calluses on MTPs, feet with normal sensation (5.07
monofilament) and vibration

VS: BP 165/90, P 98, RR 18, T 37°C; waist circ 38 in, Wt 240 lbs (109 kg), Ht 5'8''
Labs

Na 139 mEq/L Ca 9.4 mg/dL Fasting Lipid Profile:

K 3.6 mEq/L Phos 3.3 mg/dL T. chol 236 mg/dL
Cl 103 mEq/L AST 15 IU/L LDL 135 mg/dL
CO2 31 mEq/L ALT 18 IU/L HDL 56 mg/dL

BUN 15 mg/dL Alk Phos 62 IU/L Trig 223 mg/dL

SCr 0.8 mg/dL T. bili 0.4 mg/dL TC/HDL ratio 4.2
Gluc (random) 74 mg/dL Hg A1c 9.8%

UA
1+ protein, (+) microalbuminuria

Assessment: The patient reports that she exercises at most once a week and her diet is
difficult to maintain due to the nature of her job as a delivery person. Her glycemic control has
been maintained with an 8.9% Hg A1c 6 months ago. She has had a moderate weight gain of
15 lb (6.8 kg) over the past year. Her blood pressure and cholesterol are not at goal on the
current drug therapy.

Please utilize the following resources in order to determine the appropriate management
for Mrs. Martin’s worsened DM.

1) What do the 2019 American Diabetes Association (ADA) guidelines say about initiation of
therapy in patients with Type 2 Diabetes Mellitus? What non-pharmacologic therapy should be
discussed and initiated in this patient?
https://care.diabetesjournals.org/content/diacare/suppl/2018/12/17/42.Supplement_1.DC1/DC_4
2_S1_2019_UPDATED.pdf S92 & S165

2) What concerns and risks exist regarding the use of glyburide with regard to side effects and
efficacy as monotherapy?
a) (http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=a56f100f-0f42-4188-81ab-
04644b824040)
b) http://online.lexi.com/lco/action/home?siteid=9153
3) In order to follow the ADA guidelines, you decide to discontinue therapy with glyburide and
initiate metformin therapy. What dose should Mrs. Martin be started on? How should dose
titration be approached and why? What monitoring is necessary in patients on metformin
therapy? (dose, monitoring and literature to support starting this)
a) http://online.lexi.com/lco/action/home?siteid=9153

4) It has been three months since Mrs. Martin began a steady dose of metformin 1000mg BID.
She presents to the IMC for a follow-up visit and her Hg A1c today is now at 8.2%. Per the 2019
ADA Standards of Medical Care, you decide to initiate a second oral agent. What steps should
you use in order to determine the next step in therapy for this patient? Which would you choose
to initiate and why?
https://care.diabetesjournals.org/content/diacare/suppl/2018/12/17/42.Supplement_1.DC1/DC_4
2_S1_2019_UPDATED.pdf S94

5) Which medications have been shown to have cardiovascular benefit in patients with
diabetes?
https://care.diabetesjournals.org/content/diacare/suppl/2018/12/17/42.Supplement_1.DC1/DC_4
2_S1_2019_UPDATED.pdf S93

6) Since the initiation and maximization of a second oral agent, Mrs. Martin has had to pick up
more overnight flower delivery shifts to pay for vehicle damages that occurred while teaching
her oldest child to drive. In order to stay awake, she starts drinking one or two Monster energy
drinks a night and frequently snacks on Sweet Tarts during her deliveries. After cancelling her
previously scheduled follow-up visit five weeks ago, she returns to the IMC for an overdue DPV.
It has been 19 weeks since her last visit and she has gained 10 lbs. since then (now 264 lbs).
She admits that she is often so tired that she tends to forget to take her medications and has a
difficult time making healthy dietary choices. Her Hg A1c is 11.3% today. You ask about her
exercise habits and she exclaims, “Nobody has time for that!”.
https://care.diabetesjournals.org/content/diacare/suppl/2018/12/17/42.Supplement_1.DC1/DC_4
2_S1_2019_UPDATED.pdf S95
a) You make the decision to start her on injectable therapy. Which medications should
you consider starting in this patient?

b) You decide to initiate insulin therapy. How should insulin therapy be initiated in Mrs.
Martin?

7) Mrs. Martin understands the consequences of poorly managed diabetes and agrees to your
recommendation to begin intensive insulin therapy and self-monitoring of blood glucose
(SMBG). How would you educate Mrs. Martin on insulin injections and SMBG with respect to
frequency and technique? How should she respond to low blood sugar readings?

Some glucometer information and comparisons

(http://www.diabetesadvocacy.com/glucometers.html)

Patient information on managing hypoglycemia. There is also a hard copy of this book in the
IMC
(http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-
control/hypoglycemia-low-blood.html)

Guidelines on SMBG
https://care.diabetesjournals.org/content/diacare/suppl/2018/12/17/42.Supplement_1.DC1/DC_4
2_S1_2019_UPDATED.pdf S71

8) Mrs. Martin leaves the IMC ready to tackle the challenge of taking control of her diabetes.
After running a few errands, she stops at the pharmacy that evening to pick up her new insulin
and diabetic testing supplies. She is shocked when she hears the price and heads home without
picking up the prescriptions. When she gets home, her husband reluctantly admits that he was
laid off from his job a week ago and that the family is now without health insurance. The next
morning, she calls in to the IMC to report her inability to afford her insulin and testing supplies.
What resources are available through the IMC to help with affordability?

9) After working with the IMC staff, Mrs. Martin is happy to report that she is experiencing
significant success with her new insulin regimen. She is highly encouraged to live a healthier life
and wants to know how often she needs to follow up with you. When should follow-up visits be
scheduled and what testing (including referrals) is necessary?
https://care.diabetesjournals.org/content/diacare/suppl/2018/12/17/42.Supplement_1.DC1/DC_4
2_S1_2019_UPDATED.pdf S124

Case by: Michelle Cudnik, PharmD. Last updated January 2019