Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath
Mr. KM was referred to a diabetes center by his GP. Mr. KM is a 77-year-old man who has had type 2 diabetes for 17 years: current HbA1c 9.5%; random blood glucose 24 mmol/L; hyperlipidaemia; BP 165/70; retinopathy proliferative; renal dysfunction; cardiomyopathy and past history AMI and stent; and pacemaker in place….
- glibenclamide 10 mg BD
- gemfibrozil 150 mg daily
- irbesartan 150 mg daily
- NPH 24 units AM, 20 units PM
- Clopidogrel 75 mg daily
- Sotalol 40 mg BD
- Irbesartan 150 mg
- Referred to commence metformin.
Very tired and not sleeping. Wife is very unwell in a nursing home. Mr. KM visits her each day and spends the day holding her hand ‘which keeps her calm and helps her sleep’ and mostly sleeps sitting beside her.
Mr. KM highlights the importance of considering the individual’s specific circumstances and life priorities and not just his diabetes status. Importantly, it highlights the key role of family support in managing diabetes and the need to consider the family as well as the person with diabetes. Being tired and sleeping poorly is most likely a combination of stress and anxiety generated by having his wife in a nursing home. This is likely to contribute to his hyperglycemia, which increases his tiredness, setting up a vicious cycle. Having said that, the majority of people with long standing diabetes and poor glycemic control have an inadequate medication regimen.
Mr. KM could be depressed. Depression is an under-diagnosed complication of diabetes. Goldney et al. (2004) found that approximately 1 in 4 people with diabetes are depressed. Reynolds (1999) found a correlation between chronic conditions and major depression in older people. A mental health assessment would be very useful to determine Mr. KM’s level of stress, anxiety and depression, and devise strategies to help him cope. Suggesting his GP coordinates a management plan that may or may not involve medication may facilitate such a consultation. His cognitive status could also be assessed.
It would be helpful to review Mr. KM’s diet. He may be neglecting his diet since his wife was placed in a nursing home, and is at significant risk of malnutrition. It may be possible for the nursing home to provide him with a meal during his daily visits. It is not uncommon for family members who visit residential care facilities on a daily basis to be encouraged to have a greater role in caring for their loved ones, which may reduce their feeling of helplessness but can also be a burden. There may be activities that Mr. KM and his wife could enjoy together that involve more than holding hands and sleeping all day, which probably contributes to Mr. KM’s inability to sleep well at night.
The hyperglycemia does need to be addressed and has been present for at least 3 months judging by the HbA1c. The possibility of reduced medication compliance especially during this period of profound stress needs to be considered. A structured medication review is indicated to find a way to simplify his medicine regimen.
Metformin may be contraindicated. Mr. KM has renal dysfunction, although the degree of damage is not clear from the referral history and needs to be clarified. Renal failure is a contraindication to metformin because of the possibility of lactic acidosis, which is fatal in approximately 50% of cases. His age and high risk of becoming dehydrated are also contraindications to metformin, for the same reason. He is using two antihypertensive agents from the same class and this needs to be revised.
Long-acting sulphonylureas such as glibenclamide may not be the best choice in an older person because it has a long half-life, increasing the risk of hypoglycemia, which he may not recognize. Mr. KM’s renal impairment also increases the risk of hypoglycemia. This point is often forgotten when HbA1c is the prime focus. Hypoglycemia can still occur despite an HbA1c of 9.5% if the food intake is poor, and in an older person with impaired renal functioning it can be prolonged and severe.
A TZD could be considered depending on the degree of heart failure and could help maintain the patency of his stent. Agents such as Avandia (rosiglitazone) and Actos (pioglitazone) can be prescribed in people with diabetes with Class 1 and 2 heart failure defined by the New York Heart Association. Careful monitoring of liver function (transaminase levels) and fluid retention is required. TZDs generally take at least 3 months to show therapeutic benefit. However, given that Mr. KM also has cardiomyopathy I would not use a TZD.
An alpha-glucosidase inhibitor could be considered. Acarbose prolongs the time it takes for food to be absorbed, thereby reducing postprandial blood glucose excursions. However, it is often associated with intolerable gastrointestinal tract side effects. Generally, acarbose only reduces HbA1c by 0.5% and adding an additional tablet that must be taken after food would complicate his medicine regimen at a very stressful time. Although acarbose does not cause hypoglycemia, the other OHAs might, in which case hypoglycemia must be treated with glucose because acarbose inhibits sucrose absorption.
NPH (Protaphane) has a variable action profile and changing to a long-acting insulin analogue might reduce the complexity of his medication regimen. Rapid-acting insulin may also be needed at meal times. Possible strategies include:
- Cease NPH (Protaphane) and switch to twice-daily Levemir (detemir).
- Cease NPH (Protaphane) and switch to daily Lantus (glargine).
- Cease NPH (Protaphane) and change to twice-daily premixed insulin such as NovoMix30 or HumalogMix25 because the rapid-acting component is less likely to cause mid-morning and pre-bed hypoglycemia compared with Mixtard 30/70 or Humulin 30/70 whose fast-acting component peaks at approximately 4 hours (and therefore often late morning or at bedtime).
- Cease glibenclamide and commence gliclazide TR (modified-release gliclazide) 120 mg with breakfast. This long-acting 24-hour agent is activated when blood glucose levels rise. Alternatively, the oral agents could be ceased altogether, which would simplify the medicine regimen.
In addition, I would check Mr. KM’s insulin administration technique and the type of insulin delivery device he is using. He has proliferative retinopathy and may not be able to see to dial up the correct insulin dose or the device. According to Sinclair and Finucane (2001), 10% of older people with diabetes have sight-threatening retinopathy. NPH (Protaphane) is dispensed in a variety of devices. If his insulin was dispensed in a different device from usual Mr. KM might be confused about how to use the device. The InnoLet is often easier for older people to use because the numbers are large and dialing up is relatively easy because the device looks like an egg timer. Depressing the plunger to deliver the insulin does not require as much strength or dexterity as some other devices. The drawback is the limited range of insulins available in the InnoLet.
I would also check his insulin administration sites to assess whether he has any hypertrophy, which could affect insulin absorption. Mr. KM’s blood glucose testing technique also needs to be assessed. He may not be testing because of the stress and worry associated with his wife’s condition and may not see his health as a priority while his wife is unwell. This is an important issue to identify. Often when a spouse is unwell, the partner neglects his or her own health needs. Mr. KM needs to be aware that he needs to care for himself to be strong and well enough to assist his wife. He may need support to do so.
I would also like to exclude asymptomatic angina. Mr. KM has had one MI and his stent may no longer be patent. Asymptomatic angina is common in people with diabetes. An estimated one in five AMIs occur without symptoms in this population. Measuring his creatine kinase (CK) and an ECG would be useful.
- Fibrates (Jezil, gemfibrozil) are contraindicated in severe renal impairment and may need to be reviewed once the degree of renal impairment is established.
- Mr. KM is prescribed both Karvea (proprietary name) and ibesartan (generic name): both are angiotensin-II antagonists. Insomnia is an infrequent side effect of the angiotensin-II antagonists. Mr. KM is taking two of these agents, which could contribute to his difficulty sleeping.
- An additional consideration related to his poor sleeping patterns is obstructive sleep apnoea (OSA). If it is not diagnosed and treated, OSA results in a very poor sleep during the night and the necessary deep sleep and relaxation are compromised.
Diabetes educator 2
I agree with this comprehensive assessment. Treatment decisions in older people with diabetes are complicated by many factors including health status and life expectancy. Many older people express a desire to maintain their independence, and avoiding the burden of complex self-care and medicine regimens is often valued over longevity. Mr. KM’s desires in this respect may influence his management. He has considerable health risks, which will also influence the management. Controlling lipids and hypertension may confer greater benefits than controlling blood glucose (Durso 2006).
There is evidence that daily glargine in combination with oral glucose-lowering agents simplifies the medicine regimen and achieves acceptable blood glucose control with a lower risk of hypoglycemia in older people (Janka et al. 2005).
This gentleman needs excellent control. Metformin is contraindicated because of the renal insufficiency and adding a glitazone would be my choice, possibly with a long-acting insulin analogue.
The aims of the book are to: (1) address commonly encountered diabetes management problems; (2) develop comprehensive responses from a range of relevant health professionals who suggest management approaches relevant to their area of practice. The speciﬁc health professionals who provide comments about each case depend on the speciﬁc clinical issue; and (3) stimulate thought and discussion.
The target readership is health professionals from a range of professional backgrounds and general as well as specialist professionals such as general practitioners, nurses, dietitians, and podiatrists. The book will be particularly useful for beginner practitioners specializing in diabetes. In addition, it will provide suggestions or food for thought for more experienced practitioners. The cases will be excerpts from the book are all real and are presented exactly as the information was received from the person making the referral. General practitioners, diabetes educators and people with diabetes referred most of the cases; some were self-referrals by people with diabetes. They represent referrals to various diabetic health professionals and concern commonly encountered clinical issues.
Next Week: Another Case Discussion
For more information on the book, just follow this link to Amazon.com, Managing Clinical Problems in Diabetes
Copyright © 2008 by Blackwell Publishing Ltd, UK
Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath