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Patient Presentation and History

Chief Complaint: the patient’s wife is bringing the patient in after a fall at their home

Presentation:

J.S. a 50-year-old African American male who presents with his wife after he fell at home. After the fall, he told his wife “I will be fine, I think my vision just needs checked.” The patient reports, “I was walking very fast because I really had to pee and I accidentally ran into the table and got off balance. The next thing you know I was on the ground.” The patient reports having blurred vision for the past couple of months but just has not had the time to go to the eye doctor. His wife is more concerned about other changes she has noticed such as, J.S. has been waking up 3 times a night to go to the bathroom and he has had slight confusion and forgetfulness at times. J.S. thinks he has been using the bathroom more frequently because he has been so thirsty lately due to the warmer weather. When asked further about the fall the patient does report some tingling in both his feet occasionally. The patient’s wife also thinks her husband’s legs are getting weaker because he hasn’t been able to go on as long of a walk, like they normally do.  She also expressed concern about a cut J.S. got on his leg that has not healed. The patient believes he got the cut about 2 months ago while mowing the lawn.

Past Medical History:

Obesity (1999)                                                                                           

GERD (2005)                                                  

Anxiety (2015)

Obstructive Sleep Apnea (2017)

Surgical History:

Appendectomy (1995)

Tonsillectomy (2017)

Pertinent family history:

Father—alive; type 2 diabetes, hypertension

Mother—hyperlipidemia, died of a stroke at age 70

Sister—alive, unremarkable medical history

Pertinent Social history:

J.S. works at a bank where he is primarily sitting at a desk all day. He reports  gaining more weight recently so he and his wife have started going on walks around the neighborhood each night for exercise. He reports it is hard for him to eat healthy because he works long hours and “fast food is easy”. J.S. does report having “a bad smoking habit” of half a pack a day (12 pack years). He says it helps with his anxiety and stress of his job. The patient only reports social drinking (~2 drinks per week).

  Current Medications:

Xanax-.5 mg BID

Prilosec-20 mg Daily

  Assessment & Vitals:

Height: 5’9”

Weight: 255 lbs.

Temp: 98.7°F

P: 85 bpm, apically, regular rhythm

RR: 16 breaths/minute, unlabored

BP: 127/78 mmHg, left arm, sitting

Pain: patient reports no pain at this time

Skin: open cut on lower left leg ~2 inches in length, erythema surrounding cut, no drainage

Peripheral neurovascular: positive for tingling in bilateral lower extremities

  Lab Results:

Lipid panel:

         HDL: 45 mg/dL

         LDL: 105 mg/dL

        Triglycerides: 140 mg/dL

         Total: 190 mg/dL

Fasting blood glucose: 240

TSH: 2.0 mU/L

Urine Analysis: normal except:

        Glucose: 3.0 mmol/L

Chem 7: within normal limits

Case Study: Using Insulin in a Younger Patient with Poorly Controlled T2D

—despite near-maximal doses of metformin and a glp-1 receptor agonist, this patient’s a1c is 7.8%. why.

By Kirstin Bass, MD, PhD Reviewed by Carol H. Wysham, MD

This case illustrates the considerations required for early introduction of basal insulin in a patient with poor glycemic control on two oral medications.

Case presentation

A 40-year-old white elementary school teacher presents for follow-up of his uncontrolled type 2 diabetes. He was diagnosed 5 years ago, at which time he attended diabetes education classes and was started on metformin 500 mg twice daily, which was increased to 1000 mg twice daily a year later. Two years ago, the glucagon-like peptide 1 (GLP-1) receptor agonist liraglutide was added and titrated up to the maximum tolerated dose of 1.2 mg daily.

The patient’s hemoglobin A1c has been between 6.0% and 6.9% until this visit. Since his last visit a year ago, he reports that he has noted a gradual increase in his fasting glucose levels from an average of 120 to an average of 160. He eats a low-fat, high-fiber diet and walks for 30 minutes most days of the week. He reports that he gets between 7 and 8 hours of sleep per night. His weight has not changed since his last visit. His current medications are:

• Atorvastatin, 20 mg daily
• Liraglutide, 1.2 mg daily
• Lisinopril, 20 mg daily
• Metformin, 1000 mg twice a day

On his physical exam, he weighs 219 lb and is 70 in tall; BP is 130/80 mm Hg, and his pulse is 68 BPM. His abdomen is soft with central obesity. He has no tenderness or organomegaly. Retinopathy and thyromegaly are absent. His lungs are clear, heart rate and rhythm are normal, there are no foot deformities or edema, and pedal pulses are present and normal. The neurologic exam is also normal.

Of note, this patient has a hemoglobin A1c of 7.8%, which is much higher than his target hemoglobin A1c of 1 While the American Diabetes Association (ADA) recommends that patients with diabetes have a hemoglobin A1c of 1 This patient is very young, has no complications, and a long life expectancy; for these reasons, an attempt at tight glycemic control should be made to prevent both microvascular and macrovascular complications, as tight glycemic control has been shown to reduce the risk for myocardial infarction in people with a short duration of diabetes. 2,3 With his hemoglobin A1c of 7.8%, this patient has poorly controlled type 2 diabetes, despite maintenance of a healthy lifestyle and treatment with two oral antihyperglycemic agents.

Treatment recommendations

According to the American Diabetes Association (ADA)/European Association for the Study of Diabetes (EASD) position statement for treatment of hyperglycemia in type 2 diabetes the addition of a third agent at this point is appropriate. 1 This is also supported by the American Association of Clinical Endocrinologists treatment algorithm. 4 As this patient is already taking metformin plus a GLP-1 receptor agonist, the recommended options include addition of a sulfonylurea, the thiazolidinedione pioglitazone, or basal insulin. 1 Due to a lack of trial data to support their use at the time of publication, the ADA/EASD did not support the addition of sodium glucose transporter 1 (SGLT-1) inhibitors in combination with GLP-1 receptor agonists. 1 However, a subanalysis of the CANVAS trial recently demonstrated safety and efficacy for this combination. 5

While the sulfonylureas are effective in controlling glucose levels, use of these agents is associated with modest weight gain and a risk of hypoglycemia. 1 As this patient is a teacher, the risk of hypoglycemia was very undesirable for him, and so he did not wish to pursue this option. The thiazolidinedione pioglitazone was another option, and this class of drugs does not increase the risk of hypoglycemia, unlike the sulfonylureas. However, adverse effects of this drug include significant weight gain, fluid retention, and an increased risk of bone fractures. 1 Given his young age and relatively active lifestyle, the patient did not wish to pursue this option, preferring an alternative with less risk of weight gain.

An advantage to using insulin at this point for the case patient is his age. The United Kingdom Prospective Diabetes Study showed that the majority of patients with newly diagnosed diabetes would likely require insulin within 9 years of diagnosis. 2 The ORIGIN study randomized 12,537 patients with cardiovascular risk factors and impaired fasting glucose, impaired glucose tolerance, or type 2 diabetes to receive insulin glargine or standard care. 6 Results from this study showed that patients with impaired glucose tolerance or early diabetes who were started on basal insulin were able to achieve durable glucose control with a modest increase in the rate of hypoglycemia and modest weight gain. 6,7 Maintenance of a lower hemoglobin A1c was more likely in those patients who had a lower baseline A1c. 7

Finally, in the Treat-to-Target trial of 756 overweight patients with inadequate glycemic control taking one to two oral agents, addition of systematically titrated bedtime basal insulin was able to achieve a hemoglobin A1c 8 Pooled data from 12 prospective, randomized, controlled studies with a total of 2313 participants who were taking insulin glargine also confirmed that a lower hemoglobin A1c at baseline is associated with increased likelihood of reaching the target A1c. However, this analysis also found that lower baseline hemoglobin A1c was associated with a higher likelihood of experiencing confirmed hypoglycemic events. 9

Treatment outcomes

After discussing the treatment options, the patient agreed to initiate insulin glargine U-100 at 20 units (0.2 U/kg) every morning. The patient was instructed to increase the dose by 1 unit every day until his morning blood glucose was 120 mg/dL. When he returned 1 month after beginning this regimen, he had titrated his insulin up to 45 units. Most of his morning blood glucose readings were less than <120 mg/dL. At 3 months into this treatment regimen, his hemoglobin A1c was 6.4%. He rarely experienced hypoglycemia, and when it occurred it was usually related to increased activity. His weight increased by 1.5 pounds.

When patients with type 2 diabetes fail to achieve glycemic control while taking one to two oral antihyperglycemic agents, the addition of another agent should be considered. Another oral agent can be considered, but data also support the early initiation of insulin to achieve durable glycemic control.

Published: November 16, 2016

• 1. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes, 2015: a patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care . 2015;38:140-149.
• 2. Turner RC, Cull CA, Frighi V, Holman RR. Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes mellitus: progressive requirement for multiple therapies (UKPDS 49). UK Prospective Diabetes Study (UKPDS) Group. JAMA . 1999;281:2005-2012.
• 3. UKPDS Study Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet . 1998;352:837-853.
• 4. Garber AJ, Abrahamson MJ, Barzilay JI, et al. AACE/ACE comprehensive diabetes management algorithm 2015. Endocr Pract . 2015;21:438-447.
• 5. Fulcher G, Matthews DR, Perkovic V, et al. Efficacy and safety of canagliflozin when used in conjunction with incretin-mimetic therapy in patients with type 2 diabetes. Diabetes Obes Metab . 2016;18:82-91.
• 6. ORIGIN Trial Investigators, Gerstein HC, Bosch J, et al. Basal insulin and cardiovascular and other outcomes in dysglycemia. N Engl J Med . 2012;367:319-328.
• 7. ORIGIN Trial Investigators. Characteristics associated with maintenance of mean A1C Diabetes Care . 2013;36:2915-2922.
• 8. Riddle MC, Rosenstock J, Gerich J; Insulin Glargine 4002 Study Investigators. The Treat-to-Target trial: randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. Diabetes Care . 2003;26:3080-3086.
• 9. Riddle MC, Vlajnic A, Zhou R, Rosenstock J. Baseline HbA1c predicts attainment of 7.0% HbA1c target with structured titration of insulin glargine in type 2 diabetes: a patient-level analysis of 12 studies. Diabetes Obes Metab . 2013;15:819-825.

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Diet in Diabetes: One Size Doesn’t Fit All

Potential Risks of Anti-obesity Medications in Patients with T2D

Treating the Root Cause: Diabetes Medicine

Clinical Case 2: Adult Patient with Hypertension and Diabetes

• First Online: 19 August 2016

Cite this chapter

• Arrigo F. G. Cicero 3  

Part of the book series: Practical Case Studies in Hypertension Management ((PCSHM))

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Woman, 64 years old, occasional smoker at a young age (4–5 smoked cigarettes per week for 10 years), overweight since menopause (at the age of 51) and her blood pressure began to increase. Seven years ago , she was discovered to be affected by type 2 diabetes, initially controlled with diet only and then treated with metformin and glibenclamide. Initially, her hypertension was treated with enalapril 20 mg, but lately her GP added hydrochlorothiazide 25 mg 1 tablet taken at 12 noon, because of suboptimal BP control. The patient is really worried for her health, fearing about the possible long-term effects of high blood pressure and type 2 diabetes on her survival.

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Cicero, A.F.G. (2016). Clinical Case 2: Adult Patient with Hypertension and Diabetes. In: Hypertension and Metabolic Cardiovascular Risk Factors. Practical Case Studies in Hypertension Management. Springer, Cham. https://doi.org/10.1007/978-3-319-39504-3_2

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Case Study: A Patient With Uncontrolled Type 2 Diabetes and Complex Comorbidities Whose Diabetes Care Is Managed by an Advanced Practice Nurse

• G. Spollett
• Published 2003
• Diabetes Spectrum

5 Citations

Management of ketosis-prone type 2 diabetes mellitus., integrating a pico clinical questioning to the ql4pomr framework for building evidence-based clinical case reports, nursing practice guideline for foot care for patients with diabetes in thailand, goal-driven structured argumentation for patient management in a multimorbidity setting, logic and argumentation: third international conference, clar 2020, hangzhou, china, april 6–9, 2020, proceedings, 18 references, using a primary nurse manager to implement dcct recommendations in a large pediatric program, diabetes in urban african americans. iii. management of type ii diabetes in a municipal hospital setting., primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial., caring for a child with diabetes: the effect of specialist nurse care on parents' needs and concerns., standards of medical care for patients with diabetes mellitus, management of patients with diabetes by nurses with support of subspecialists., a practical approach to type 2 diabetes., the diabetes control and complications trial (dcct): the trial coordinator perspective, oral antihyperglycemic therapy for type 2 diabetes: scientific review., caring for feet: patients and nurse practitioners working together., related papers.

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Case Study: Hyperglycemia, concern for diabetic ketoacidosis, and type 1 diabetes

History of present illness.

The patient is a 36-year-old man who has had type 1 diabetes for 15 years. He presents to the emergency room with hyperglycemia and concern for possible diabetic ketoacidosis after not taking his insulin for 3 days. The patient reports that he is currently homeless and has lost his supply of insulin, syringes, glucose meter, and related glucose testing supplies.

Diabetes-related comorbidities/complications

Hypertension, hyperlipidemia, retinopathy, and bipolar disorder

Diabetes related history

The patient states that at the time of his initial diagnosis with type 1 diabetes , he was hospitalized, with a glucose value >1000 mg/dL, and he was experiencing polyuria, polydipsia, and polyphagia. He reports that he has been on insulin since the time of his diagnosis, and he has never been prescribed oral agents for diabetes management. He recalls that glutamic acid decarboxylase  (GAD) antibodies and a C-peptide level have been previously evaluated. GAD antibodies were positive, and C-peptide value was low, helping to confirm the diagnosis of type 1 diabetes.

Most recently, he has been using insulin glargine 55 units once daily, and insulin aspart per correction doses 3 times daily. There was an imbalance when comparing his basal and bolus insulin doses. When asked about meal doses of insulin aspart, the patient relates that he is currently homeless and eats when food is available, often snacking on bits of food throughout the day. He was not using a meal dose of insulin aspart, but he would use this insulin to correct for hyperglycemia.

The patient has had previous episodes of diabetic ketoacidosis, for which he was hospitalized. With this episode of hyperglycemia, he is not experiencing any nausea, vomiting, or abdominal discomfort, and he appears well. The patient has no recent concerns for hypoglycemia. He reports that with past episodes of hypoglycemia, he experienced sweatiness and shakiness, for which he treated with juice or food.

Laboratory values on admission

• Creatinine: 0.9 mg/dL with eGFR >60 mL/min
• Aspartate aminotransferase (AST): 17 U/L
• Alanine aminotransferase (ALT): 14 U/L
• Beta-hydroxybutyrate: 0.1 mmol/L
• Bicarbonate: 25 mEq/L
• Anion Gap: 14 mEq/L

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• Diabetes & Primary Care
• Vol:24 | No:06

Interactive case study: The elderly and type 2 diabetes

Share this article + Add to reading list – Remove from reading list ↓ Download pdf

Diabetes & Primary Care ’s series of interactive case studies is aimed at all healthcare professionals in primary and community care who would like to broaden their understanding of diabetes.

The care of older people with type 2 diabetes is complicated, as the prognosis and appropriate treatment goals vary greatly between individuals. The three mini-case studies developed for this issue of the journal take us through the basic considerations of managing type 2 diabetes in the elderly.

The format uses typical clinical scenarios as tools for learning. Information is provided in short sections, with most ending in a question to answer before moving on to the next section.

Working through the case studies will improve our knowledge and problem-solving skills in diabetes care by encouraging us to make evidence-based decisions in the context of individual cases.

Readers are invited to respond to the questions by typing in your answers. In this way, we are actively involved in the learning process, which is hopefully a much more effective way to learn.

By actively engaging with these case histories, I hope you will feel more confident and empowered to manage such presentations effectively in the future.

Marianne , who is 71 years old, has type 2 diabetes but lives a very active life, with little in the way of comorbidities. However, despite treatment with metformin 1000 mg twice daily, her glycaemic control has deteriorated in recent years.

Mike is 78 years old and has long-standing type 2 diabetes. Six years ago he suffered a myocardial infarction. He takes a range of medication to address his hyperglycaemia, hypertension and low mood. He lives alone, but uses a stick to walk and receives practical help from his daughter. Recently, he has been experiencing shakiness and sweating after gardening, and dizziness on standing. His BP is 117/58 mmHg and HbA 1c is 51 mmol/mol.

Claire is an 81-year-old who lives in a care-home. She has Alzheimer’s disease and long-standing type 2 diabetes. A stroke 4 years ago left her with unilateral weakness, and she has frequent lower urinary tract infections and episodes of urinary incontinence. For her hyperglycaemia, hypertension and various other health concerns, she is taking over a dozen medications. A review of her diabetes is due.

The health and care needs of each of these people differ greatly. By working through their case studies, we will consider the following issues, and more:

• Agreeing glycaemic targets in the elderly.
• Assessment of frailty and the importance of a holistic approach to managing diabetes in the elderly. 
• Choice of medications and concerns over hypoglycaemia.
• Deintensification and simplification of medication regimens.

Click here to see the case study.

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Case Study: Remission of Type 2 Diabetes After Outpatient Basal Insulin Therapy

Sierra c. schmidt.

1 Auburn University Harrison School of Pharmacy, Auburn, AL

Martha Ann Huey

Heather p. whitley.

2 Baptist Health System, Montgomery Family Medicine Residency Program, Montgomery, AL

Diabetes is a chronic, progressive disease with potentially serious sequelae. Treatment for type 2 diabetes often begins with oral agents and eventually requires insulin therapy. As the disease progresses, drug therapies are often intensified and rarely reduced to control glycemia. Conversely, in type 1 diabetes, some patients experience a “honeymoon period” shortly after diagnosis, wherein insulin needs decrease significantly before intensification is needed ( 1 ). No comparable honeymoon period has been widely described for type 2 diabetes. However, a few studies have demonstrated that drug-free glycemic control can be achieved in type 2 diabetes for 12 months on average after a 2-week continuous insulin infusion ( 2 – 4 ). Here, we describe an unusual case of a 26-month drug holiday induced with outpatient basal insulin in a patient newly diagnosed with type 2 diabetes.

Case Presentation

A 69-year-old white woman (weight 72.7 kg, height 59 inches, BMI 32.3 kg/m 2 ) was diagnosed with type 2 diabetes in June 2011. She presented with an A1C of 17.6% (target <7%) and a fasting blood glucose (FBG) of 452 mg/dL (target 70–130 mg/dL). Before diagnosis, the patient had not used any oral or parenteral steroids nor had she experienced any traumatic physical or emotional event or illness that could have abruptly increased her blood glucose. Metformin 500 mg twice daily was initiated at diagnosis, but was discontinued 9 days later to avoid risk of lactic acidosis, as her serum creatinine was 1.5 mg/dL. At that time, her fasting self-monitoring of blood glucose (SMBG) values ranged from 185 to 337 mg/dL. Treatment with 25 units of insulin detemir daily (0.34 units/kg/day) was initiated in place of metformin. The patient was counseled on diet modifications and encouraged to exercise.

One month later (July 2011), the patient’s fasting SMBG values had improved to a range of 71–212 mg/dL with a single hypoglycemic episode (58 mg/dL); her weight and BMI increased slightly to 74.1 kg and 32.9 kg/m 2 , respectively. Hypoglycemia education was reinforced, and insulin therapy was switched from 25 units of detemir delivered with the Levemir FlexPen to 28 units (0.38 units/kg/day) of insulin glargine delivered with the Lantus SoloStar due to the patient’s preference for this device. Two weeks later, the patient reported continued improvements in fasting SMBG (70–175 mg/dL) with one hypoglycemic episode (67 mg/dL). In response to the hypoglycemic episode, her insulin glargine dose was decreased to 25 units daily.

In September, the patient reported fasting SMBG values ranging between 71 and 149 mg/dL, and her A1C was 7.9%. On days when the patient skipped lunch, her midday blood glucose level would drop to <70 mg/dL (54–60 mg/dL). She was counseled not to skip meals, and her insulin glargine dose was maintained.

In October, the patient’s weight was 71.4 kg, and her BMI was 31.7 kg/m 2 . She reported recently initiating a cinnamon supplement and switching her beverage intake from sugar-sweetened products to water and diet soda. Although the majority of her fasting SMBG values were controlled (80–110 mg/dL), she had experienced six hypoglycemic episodes (FBG 13–64 mg/dL). All values were objectively confirmed in the patient’s glucose meter, and the meter was replaced in case of device error. Her daily insulin glargine dose was decreased to 20 units (0.28 units/kg/day).

In December, her SMBG values ranged between 70 and 106 mg/dL preprandially and 111 and 207 mg/dL postprandially, and she had had six additional hypoglycemic episodes (42–66 mg/dL). The patient’s weight remained stable at 71.4 kg (BMI 31.7 kg/m 2 ). At this follow-up visit, her daily insulin glargine dose was decreased further to 15 units (0.21 units/kg/day).

The patient self-discontinued daily insulin glargine in March 2012 but continued using the cinnamon supplements. She continued to perform SMBG 1–3 times/day, anticipating loss of glycemic control. During the next 2 years, her A1C remained stable (from 6.3% in January 2012 to 6.9% in May 2014) ( Figure 1 ).

Daily basal insulin dose and A1C over time. Black triangle = insulin units; black square = A1C.

At a follow-up visit in May 2014, the patient’s SMBG indicated a need for resumed drug therapy (FBG 107–169 mg/dL, postprandial blood glucose 108–328 mg/dL). Her weight at this time was 65.5 kg (BMI 29.1 kg/m 2 ). Insulin glargine was reinitiated at 5 units daily (0.08 units/kg/day).

During the drug-free period of March 2012 to May 2014, the patient maintained her lack of sugar-sweetened beverage consumption. However, she reported having difficulties purchasing healthy food options because of financial constraints. In August 2013, she was specifically encouraged to incorporate physical activity (walking) into her daily routine. The patient’s weight during the drug-free interval declined from 70 kg in March 2012 to 65.5 kg in May 2014.

Hyperglycemia causes pancreatic β-cell toxicity, leading to decreased insulin release ( 3 ). In type 1 diabetes, the honeymoon period occurs when residual pancreatic β-cell function is partially restored for an average of 7.2 months, as hyperglycemic stress is removed before the β-cells are ultimately destroyed ( 1 , 3 ).

Past studies demonstrated induction of a drug-free period when patients newly diagnosed with type 2 diabetes were treated with 2–3 weeks of intensive insulin therapy ( 2 – 5 ). Ilkova et al. ( 2 ) induced a 12-month drug-free period in 46.2% ( n = 6) of patients using an insulin infusion averaging 0.61 units/kg/day. Three patients maintained glycemic control for 37–59 months. Li et al. ( 3 ) also induced a 12-month drug-free period in 47.1% ( n = 32) of patients with an insulin infusion of 0.7 units/kg. Additional studies indicate that basal-bolus insulin therapy (0.37–0.74 units/kg/day) using NPH and regular insulin can also induce a 12-month drug-free period in a similar percentage of patients (43.8–44.9%) ( 4 , 5 ).

The mechanism of remission appears to be related to resumption of endogenous insulin production after glucotoxicity is resolved. Glucotoxicity has been shown to inhibit first-phase insulin secretion from the pancreatic β-cells ( 3 ). Li et al. ( 3 ) theorized that an insulin infusion corrects hyperglycemia and removes stress from the β-cells, allowing them to produce insulin, resulting in euglycemia. Their study quantified an increase in secretion of endogenous insulin (44%) and C-peptide (26%) after 2 weeks of continuous insulin infusion. The mechanism through which insulin induces a period of drug-free glycemic control in type 2 diabetes appears to be similar to that causing the honeymoon period in type 1 diabetes.

To our knowledge, this is the first report of basal insulin monotherapy–induced remission of type 2 diabetes. Previous studies required multiple daily injections in a basal-bolus therapy regimen using NPH and regular insulin or hospitalization of patients administered a continuous insulin infusion ( 2 – 5 ).

Basal-only insulin therapy may be a slower method of achieving remission compared to more intensive insulin regimens. In this case, basal insulin was maintained for 9 months. However, according to the FBG trend, discontinuation could have occurred sooner. This report suggests that a trial of basal insulin dosed at 0.2–0.3 units/kg/day, with follow-up every 2–4 weeks in severely hyperglycemic patients with newly diagnosed type 2 diabetes, may be an alternative method to achieving temporary remission. Although this insulin regimen requires a longer timeframe compared to remission induced by basal-bolus therapy or continuous insulin infusion, it provides a more convenient outpatient therapeutic option at a lower cost.

Limitations of this case study include the patient’s use of cinnamon supplementation, which was continued throughout the drug-free period. Although reports are conflicting regarding its efficacy in type 2 diabetes, it is possible that cinnamon may have exerted a mild antidiabetic effect. Positive cinnamon studies have demonstrated a 0.36% A1C reduction after 3 months of use ( 6 ). Additionally, the patient’s weight declined by 3.75% during the 9 months of basal insulin therapy, which was likely in response to introducing dietary modifications related to beverage consumption. Most studies suggest that an A1C reduction of 0.36% ( 7 ) to 0.66% ( 8 ) can be achieved with intensive lifestyle interventions. Therefore, it is unlikely that cinnamon in combination with the mild lifestyle modifications accounted for a nearly 11% A1C reduction from baseline.

Eliminating the consumption of sugar-rich beverages alters the postprandial glycemic curve. In clinical practice, suppressing postprandial blood glucose excursions by adopting significant dietary improvements may postpone or obviate the need for bolus insulin therapy. Likewise, the remission of diabetes potentially may be achieved, as seen in this case, with monotherapy basal insulin when dietary modifications significantly alter the postprandial glycemic curve. However, it is unknown whether remission can be achieved using basal insulin administration alone in patients who choose not to incorporate lifestyle modifications or in patients with baseline healthy eating and exercise habits.

Although weight changes did not appear to contribute to disease remission, the moderate weight loss (6.5%) achieved during the drug-free interval and continued SMBG both may have contributed to maintaining and extending the remission period. The Diabetes Prevention Program ( 9 ) showed that lifestyle modifications aimed at achieving a 7% reduction of weight significantly delay the onset of diabetes compared to placebo and metformin. Finally, performing SMBG through the drug-free period may have empowered the patient by providing objective criteria necessary to validate the benefits of lifestyle modifications.

Based on this case, it is possible that initial type 2 diabetes management with basal insulin can temporarily restore β-cell function to a degree to which blood glucose control can be maintained without drug therapy. Although previous studies conducted with intensive insulin regimens have reported response rates nearing 50% for ∼12 months ( 2 – 5 ), future studies should investigate the ideal basal dose, percentage of patient responders, duration of drug-free glycemic control, and mechanism through which this phenomenon occurs. This case further highlights the need to educate every newly diagnosed patient about the treatment of hypoglycemic events.

The purposeful remission of diabetes is not widely attempted or generally considered possible. Although literature exists regarding the temporary honeymoon period experienced after insulin initiation in some people with type 1 diabetes ( 1 ), comparatively little research is available regarding the influence of insulin on the remission of type 2 diabetes. Current literature suggests benefit in nearly 50% of patients newly diagnosed with type 2 diabetes using one of the following strategies: a 2-week inpatient insulin infusion or multiple daily injections of basal-bolus therapy ( 2 – 5 ). However, there are disadvantages to these methods. A continuous insulin infusion requires inpatient admission, whereas a basal-bolus insulin regimen requires purchase of two products and administration of multiple subcutaneous injections daily. Unfortunately, both methods may be impractical, costly, and inconvenient for many patients newly diagnosed with type 2 diabetes.

This case outlines a third potential option for inducing remission of type 2 diabetes: basal insulin monotherapy. Using this approach avoids the costly and inconvenient hospital admission required for the continuous insulin infusion strategy. Furthermore, the cost of drug therapy is reduced with the purchase of one rather than two insulin products, as needed in a basal-bolus insulin regimen. Additionally, using basal insulin alone reduces the risk of hypoglycemic events that may occur with stacking of multiple insulin products. Finally, requiring only one injection of insulin each day offers a more manageable alternative for newly diagnosed patients compared to the multiple daily injections required with a basal-bolus insulin regimen.

By using this basal insulin strategy, the patient in this case was able to achieve drug-free glycemic control for 26 months. Early initiation of basal insulin monotherapy in patients newly diagnosed with type 2 diabetes is a more convenient and cost-effective approach than methods previously described and could potentially induce remission of type 2 diabetes in other patients.

Duality of Interest

No potential conflicts of interest relevant to this article were reported.

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Lifestyle medicine case manager nurses for type two diabetes patients: an overview of a job description framework—a narrative review.

1. Introduction

2. materials and methods, 2.1. study design, 2.2. identification of the research question, 2.3. inclusion and exclusion criteria, 2.4. search strategy, 2.5. data extraction and synthesis, 3.1. preliminary literature analysis, 3.2. literature screening, 3.3. general characteristics of studies included, 3.4. overview of the role and clinical applications of lmcmns at the international level, 3.5. overview of the role and clinical applications of specialist nurses in italy, 3.6. academic pathways for specialist nurses and case managers in italy, 3.7. job description for delphi method purposes, 4. discussion, limitations, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest, appendix a. search strategy, appendix a.1. pubmed search strategy, appendix a.2. scopus search strategy.

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Cangelosi, G.; Mancin, S.; Pantanetti, P.; Nguyen, C.T.T.; Morales Palomares, S.; Biondini, F.; Sguanci, M.; Petrelli, F. Lifestyle Medicine Case Manager Nurses for Type Two Diabetes Patients: An Overview of a Job Description Framework—A Narrative Review. Diabetology 2024 , 5 , 375-388. https://doi.org/10.3390/diabetology5040029

Cangelosi G, Mancin S, Pantanetti P, Nguyen CTT, Morales Palomares S, Biondini F, Sguanci M, Petrelli F. Lifestyle Medicine Case Manager Nurses for Type Two Diabetes Patients: An Overview of a Job Description Framework—A Narrative Review. Diabetology . 2024; 5(4):375-388. https://doi.org/10.3390/diabetology5040029

Cangelosi, Giovanni, Stefano Mancin, Paola Pantanetti, Cuc Thi Thu Nguyen, Sara Morales Palomares, Federico Biondini, Marco Sguanci, and Fabio Petrelli. 2024. "Lifestyle Medicine Case Manager Nurses for Type Two Diabetes Patients: An Overview of a Job Description Framework—A Narrative Review" Diabetology 5, no. 4: 375-388. https://doi.org/10.3390/diabetology5040029

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Prevalence and associated factors of anaemia in patients with type 2 diabetes mellitus: a cross-sectional study in a tertiary care medical unit, Sri Lanka

Affiliations.

• 1 National Hospital Kandy, Kandy, Sri Lanka. [email protected].
• 2 National Hospital Kandy, Kandy, Sri Lanka.
• PMID: 39174984
• DOI: 10.1186/s12902-024-01681-7

Background: Anaemia is a global public health issue that impacts individuals of all ages in both developed and developing countries. Anaemia is common in patients with diabetes mellitus; however, it is often undiagnosed and untreated. The main aim of this study was to assess the prevalence and associated factors of anaemia in patients with type 2 diabetes mellitus admitting to a medical unit at National Hospital Kandy.

Methods: A descriptive, cross-sectional study was conducted in type 2 diabetes mellitus (T2DM) patients admitted to a medical ward at National Hospital Kandy (NHK). They were assessed with a pre-tested, interviewer-administered, structured questionnaire using consecutive sampling method. The data was entered and analyzed using SPSS 26.

Results: Total 252 patients with diabetes were included. The prevalence of anaemia in patients with T2DM was 31.3%. The corresponding values for males and females were 34.2% and 65.8% respectively. Independent predictors for anaemia among diabetic patients were older age, female gender, poor glycemic control, diabetes duration > 5 years, diabetic nephropathy, retinopathy, neuropathy, stage ≥ 3 chronic kidney disease (CKD), ischaemic heart disease (IHD), peripheral vascular disease (PVD), diabetic foot ulcers (DFU) and usage of aspirin. These were significantly associated with the prevalence anemia among patients with type 2 diabetes mellitus. Multivariate logistic regression analysis revealed that female gender, age ≥ 65 years, diabetic duration > 5 years, poor glycaemic control, stage ≥ 3 CKD, diabetic nephropathy and retinopathy were associated with greater odds for the presence of anaemia.

Conclusion: We found that 31.3% T2DM patients in a medical ward at NHK had previously undiagnosed anaemia. Anaemia screening during diabetes diagnosis, maintaining glycaemic control and raising patient awareness can reduce anaemia prevalence, improve patient quality of life and potentially reduce microvascular complications.

Keywords: Anaemia; Glycaemic control; Microvascular complications; Type 2 diabetes mellitus.

© 2024. The Author(s).

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PRESENTATION

Case study: a 30-year-old man with metformin-treated newly diagnosed diabetes and abdominal pain.

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Ranjna Garg; Case Study: A 30-Year-Old Man With Metformin-Treated Newly Diagnosed Diabetes and Abdominal Pain. Clin Diabetes 1 April 2007; 25 (2): 77–78. https://doi.org/10.2337/diaclin.25.2.77

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M.P. is a 30-year-old man who was diagnosed with type 2 diabetes 2 weeks before admission to the hospital. He has a strong family history of type 2 diabetes. He smokes heavily (> 20 cigarettes/day) and admits to some alcohol consumption. His primary care physician had started him on metformin,500 mg three times daily. There were no complications of diabetes at the time of presentation. Two days before his admission, he developed generalized abdominal discomfort, watery diarrhea, and bilious vomiting. He denied any history suggestive of food poisoning or recent surgery. He was apyrexial on admission. His blood pressure was 170/101 mmHg, pulse was 100 bpm, and temperature was 98.9°F. There were no signs suggestive of peritonitis, and his abdomen was soft without guarding. He had deep-seated tenderness in the epigastric region. Initial investigations showed a white blood count of 25.9× 109, hemoglobin of 15.8 g/dl, and C-reactive protein (CRP) of 200 mg. Renal functions were normal, and liver function tests were normal except for an increased lactic acid dehydrogenase (LDH) level of 848 IU/l.

Chest X-ray showing air under diaphragm (arrows).

His metformin was stopped because his gastrointestinal symptoms were attributed to metformin. After stopping metformin, he was able to eat normally and tolerate a regular diet. He received subcutaneous insulin therapy to control his glucose levels. He continued to have some abdominal discomfort,however, and on questioning reported right shoulder pain. Shoulder examination showed no signs of inflammation. There was no restriction of movement at the right shoulder. A chest X-ray appeared to demonstrate free air beneath the diaphragm.

Why is this patient having abdominal discomfort?

What investigation would confirm the diagnosis?

How should this condition be managed?

M.P. has pneumoperitoneum (PP). PP is the presence of air within the peritoneal cavity. Most commonly, it is caused by perforated viscous(perforated gastric ulcer, bowel perforation, tumour, or trauma). PP from perforation is associated with peritonitis in most cases. 1   In this setting, sign and symptoms of peritonism are present, and patients require prompt surgical intervention. On rare occasion, PP may occur without gastrointestinal perforation. Trauma, recent surgery, barotraumas, mechanical ventilation, diagnostic procedures (e.g., endoscopy and colposcopy) are other causes of spontaneous PP without peritonitis. The cause is often identifiable from the patient's history, but in this case it was not.

Nonsurgical PP is PP that is not associated with signs of peritonitis. Patients with nonsurgical PP present with vague abdominal symptoms but do not have signs suggestive of acute abdomen. Nonsurgical PP can occur in a number of situations (e.g., silent self-sealing perforation as in patients with diabetes, patients receiving steroids, elderly patients, or critically ill patients). Deliberate air introduction into the peritoneum could also account for nonsurgical PP, as in the case of peritoneal dialysis, injury to the female genital tract (e.g., from skiing accidents), postendoscopy leakage, or ruptured pneumatosis intestinal cysts. 2  

The pain in the right shoulder noted in this case was likely referred pain. Initial abdominal discomfort and diarrhea was attributed to metformin-induced gastrointestinal side effects. When the symptoms persisted even after metformin was discontinued, search for another cause of abdominal pain revealed the correct diagnosis. This case illustrates the need to continue searching for other causes of gastrointestinal distress when symptoms do not resolve after stopping metformin. M.P.'s ultrasound scan of the abdomen showed the presence of fatty liver consistent with heavy alcohol abuse. It is also noteworthy that metformin is contraindicated in alcohol abuse and in patients at risk for dehydration. This patient, therefore, had multiple reasons to discontinue metformin. The chest X-ray showed the presence of air under the diaphragm ( Figure 1 ). An abdominal computed tomography (CT) scan showed the presence of free air within the peritoneal cavity ( Figure 2 ). There was no evidence of viscous perforation on further barium studies.

Abdominal CT scan showing presence of air within the peritoneal cavity. Arrow points to the falciparum ligament made prominent by the presence of air on both sides.

PP unaccompanied by peritonitis is usually asymptomatic. It can be diagnosed by erect chest X-ray showing the presence of air under the diaphragm. Abdominal CT scanning is the gold standard for confirming the diagnosis of PP. The CT scan is a sensitive tool and demarcates air within the peritoneal space. Once the diagnosis is confirmed, further investigations should be directed to uncover the cause and source of the air leak. Barium studies may show the perforation unless it is too small or has sealed spontaneously.

M.P. was managed conservatively. He was monitored closely. He tolerated normal meals. His diarrhea stopped. His CRP remained elevated for 2 weeks and then normalized at the time of discharge. Other markers of inflammation also improved in the same time period. Abdominal discomfort improved in 2 weeks. His blood glucose stabilized with insulin therapy. He remained fully mobile and independent and was discharged to home. He has not had any recurrences.

Nonsurgical PP has been described in the literature. Isolated cases from different pathophysiological origins have been reported. 3 - 5   Nonsurgical PP masquerading as metformin-induced gastrointestinal upset has not been reported previously. In addition to recognizing and diagnosing PP, it is important to be aware of rare nonsurgical causes of PP. Unnecessary surgery can be avoided in such cases.

Clinical Pearls

PP does not always require surgical intervention. In hemodynamically stable, minimally symptomatic patients, unusual causes of PP should be considered to avoid unnecessary surgery.

Patients with diabetes may have selflimiting small perforations that seal spontaneously. Absence of clinical signs of peritonism and the medical history of the patient can point to the nonsurgical nature of the condition.

Metformin can cause gastrointestinal upset, but other causes of such symptoms should be diligently searched for if patients remain symptomatic after stopping metformin.

Ranjna Garg, MRCP, MD, is specialist registrar at University Hospital in Birmingham, U.K.

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