Test Your Knowledge #534: A Woman with Hypertension, Obesity and Type 2 Diabetes Characterized by Prominent Postprandial Hyperglycemia Objective, Part Three of Three

Mrs. Robinson's physician complimented her compliance with her medication regimen and with performing self-blood glucose monitoring, but then explained the increased risk to her health from weight gain, worsening glycemic control, and hypertension.  The decline in kidney function was news to Mrs. Robinson and she expressed motivation to do everything possible to avoid dialysis in the future.  Although she had previously refused diabetes self-management education (DSME), she now asked to be referred to a class. She stated she would also begin taking her grandson on walks in his stroller, around the neighborhood in good weather or in the mall in bad weather.

Her physician made the following treatment changes and recommendations:

• The enalapril dose was increased to 20 mg twice daily to intensify treatment of her hypertension
• She was continued on amlodipine 10 mg daily
• Exenatide 5 µg twice daily was prescribed and instruction was provided on injection with the pen device
• A repeat serum potassium and blood pressure check was scheduled in 2 weeks
• Information on the next series of DSME classes was provided
• A decrease in intake of juice and sweets, as well as decreased use of salt in cooking and at the table, was recommended  

Follow-up: Blood pressure check

After 2 weeks on increased medication, Mrs. Robinson’s blood pressure had improved to 138/86 mmHg but was still not at goal (<130/80 mmHg). 

Her potassium level had increased to 4.9 mEq/L, which, although still within the normal range, was enough of an increase to cause her physician to call her at home with a change to her medication regimen. 

• Both amlodipine 10 mg daily and enalapril 20 mg twice daily were continued
• Furosemide 40 mg daily was added; a prescription was called in to Mrs. Robinson's pharmacy

Mrs. Robinson reported that, since starting the exenatide, she was having mild nausea after eating but felt it was getting better.

Follow-up: 4-Week clinic visit

Two weeks after her blood pressure check, Mrs. Robinson came in for another follow-up clinic visit after having an A1C, serum creatinine, and serum potassium level drawn at the out-patient lab. She reported not feeling as hungry since starting the exenatide and was watching her carbohydrate intake since attending her first DSME class. She was very pleased with the diabetes education, stating that it was being taught by a nurse and a dietitian, both diabetes educators, and she was learning about Type 2 diabetes, as well as diabetes diet and exercise guidelines. She was looking forward to attending the remaining two sessions.

She felt she was tolerating her current medication regimen well, but her knees were still bothering her.  She admitted she has not been very successful at walking on a regular basis.

Based on Mrs. Robinson’s presentation and laboratory values at the 4-week follow-up visit, what medication changes would you recommend?

1.    Stop the exenatide and start a basal-bolus insulin regimen

2.    Increase her exenatide from 5 ug twice daily to 10 ug twice daily

3.    Continue the exenatide 5 ug twice daily and add sitagliptin 50 mg

4.    Stop the exenatide and start pramlintide 60 ug prior to meals