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Case Study: The Importance of Patient-Centered Therapy

A 59 YOF is recently discharged from hospital after an allergic reaction to an anesthesia induction agent. She was placed on high-dose steroid for the reaction while she was in the hospital. Patient had completed her steroid tapering dose 2 months prior to her visit to endocrinology clinic today due to high blood glucose (a1c 8.9%). Past medical history included: hypertension, hyperlipidemia, atrial fibrillation, obesity and diabetes for 7 years. She was well controlled on metformin 1000mg BID before (all her previous A1c <7%). Patient also tried sulfonylurea before, but discontinued due to severe hypoglycemic event. While she was in the hospital, glucose control was maintained by insulin infusion. The patient was discharged on insulin glarine 20 units daily and metformin was resumed. She was instructed to titrate insulin until fasting blood glucose was 190mg/dL. Patient is frustrated with poor blood glucose control and the weight gain…

Recent updates to the AACE guideline recommend a patient-centered therapy that minimizes side effects, weight gain, and hypoglycemia, and maximize A1c lowering effects. Insulin is the drug of choice in the hospital. It is very effective in lowering A1c, but it can also increase risk for hypoglycemia and weight gain. Thus, obese patients with type 2 diabetes are often placed on dual or triple therapy with less potential for weight gain and hypoglycemia.

SGLT2 or sodium glucose cotransporter 2 lowers blood glucose by promoting the excretion of glucose in urine by inhibiting the reabsorption of filtered glucose and lower renal glucose threshold. Study showed that canagliflozin can lower A1c from 0.77-1.03% and weight-loss of 2.5-3.4kg. This drug may benefit this patient due to its lowering A1c effect and weight-loss effect. Canagliflozin also has a low risk for hypoglycemia, but it is associated with increased risk for mycotic infections, urinary tract infections, hypotension and hyperkalemia.

After 1 month of treatment with Canagliflozin, patient reported glucose readings of 150-200mg/dl (8.3-11.1mmol/L) and she had lost 9lbs. Patient also had a vaginal yeast infection that treated with fluconazole, but denied other side effects. Since patient is still above goal, GLP-1 agonist was prescribed. Patient is to start liraglutide 0.6mg daily and titrate to 1.8mg daily.

GLP-1 agonist is a hormone secreted following glucose consumption. It stimulates insulin secretion in a glucose-dependent manner and suppress glucagon secretion. Thus, GLP-1 agonist such as liraglutide can lower A1c by 0.4-1.6%. Liraglutide can also reduce weight, triglycerides and decrease blood pressure. This is an appropriate addition to the patient’s current therapy to help her achieve her A1c goal.

Three months after the addition of liraglutide, patient’s A1c is 6.6% and she had lost an additional 27 lbs.