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Managing Clinical Problems in Diabetes, Case Study #21: Prioritizing Multiple Complications

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath

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Mr. BG was referred to a diabetes multidisciplinary team by his GP. Mr. BG is a 70-year-old man. Can you help me develop an appropriate management plan? He has had diabetes since 1999. His presenting problem is a chronic cough and haemoptysis and sleep apnoea. He has a long history of a series of illnesses and surgical interventions including prostate cancer, renal calculi and minor infections such as tinea. He appears to be atopic with a history of skin allergies, hay fever and conjunctivitis. He has irritable bowel syndrome and eats a gluten-free diet. Diabetes complications include peripheral neuropathy and cardiovascular disease. He has regular acupuncture for osteoarthritis in his knees.”…

 Current medications
  • Amaryl (glimepiride) 1 mg daily with first main meal of day. With half a glass of water.
  • Atacand Plus 16/12.5 tablets 16 mg/12.5 mg 1 daily (candesartan cilexetil)
  • Co-enzyme Q10 capsule 100 mg 1 daily with food
  • Coversyl tablet – ceased 8 mg 1 daily (perindopril)
  • Diprosone lotion 0.05% BD pm (betamethasone)
  • Ditropan tablet (oxybutynin) 5 mg 1 TID
  • Iscover tablet (clopidogrel) 75 mg 1 daily
  • Metformin hydrochloride tablet 500 mg 2 BD
  • Nexium tablet (esomeprazole) 20 mg 1 daily
  • Norvasc tablet (amlodipine) 10 mg 1 mane
  • Rhinocort (budesonide) dose and dose frequency not indicated
  • Seretide (fluticasone)
Further information:
  • His current HbA1c 6.5%
  • Microalbuminuria ‘stable’ (no values provided)
  • Cholesterol 139mg/dL.(3.6 mmol/L)
  • LDL77.3mg/dL> ( 2.0 mmol/L)
  • HDL 38.6mg/sL. (1.0 mmol/L)
  • Triglycerides 124mg/Dl. (1.4 mmol/L)
  • His blood pressure is stable at present and he had a recent weight loss of 4-5 kg since consulting a naturopath.

General practitioner

Mr. BG has a long history of a series of illnesses and surgical interventions including prostate cancer, renal calculi, and minor infections such as tinea. He appears to be atopic with a history of skin allergies, hay fever, and conjunctivitis. He has irritable bowel syndrome and eats a gluten-free diet. 

Diabetes complications include peripheral neuropathy and cardiovascular disease. He has regular acupuncture for osteoarthritis in his knees. His blood pressure is reported to be stable at present but no specific information about his levels was provided. He had a recent weight loss of 4-5 kg since consulting a naturopath but we have no information about his weight status. He appears to have good control with an HbA1c of 6.5% but he has hemoptysis. However, this may not be a true reflection of his metabolic control and serum fructosamine could be considered. 

The most important issue is to investigate and manage the hemoptysis and chronic cough as a matter of urgency. The weight loss adds an ominous aspect to the case study. Cancer of the lung needs to be excluded and then other causes such as TB. Initially, a chest X-ray and sputum cytology/microculture and acid fast testing should be performed. 

If radioactive dyes are needed for any radiological interventions he will need to cease his metformin two days before the investigation and will need written advice about that. His renal function needs to be assessed to determine whether it is safe to continue metformin. The estimated glomerular filtration rate (eGFR) should be calculated rather than relying on the creatinine level alone. 

Metformin may be causing his ‘irritable bowel’ or aggravating his symptoms. Alternatively, the symptoms may be related to autonomic neuropathy, which often causes bloating, vomiting, diarrhea and fluctuating blood glucose levels. 

If surgery is required, temporarily using insulin to control his glucose levels through surgery and in the immediate postoperative phase leads to better outcomes and makes management easier. If chemotherapy is required, it can have various effects on Mr. BG’s blood glucose levels, depending on the chemotherapeutic agents used. Commencing insulin — especially if the blood glucose is erratic — can simplify the medicine regimen and make the blood glucose easier to control. The blood glucose can be affected by the chemotherapy agents (e.g., corticosteroids) as well as nausea and not eating. 

Heart disease is the most common cause of death in people with diabetes. The lipid profile suggests he is already taking a statin, which, considering his vascular disease, neuropathy, nephropathy, prostate cancer, as well as his age, puts Mr. BP as a likely candidate for surgery. 

Diabetes educator

The GP raised very important issues but did not appear to consider the implications of the weight loss following Mr. BG’s consultation with a naturopath. The weight loss may be inappropriate and related to cancer, as the GP suggested. However, it may be appropriate and improve his osteoarthritis and cardiovascular status. It would be important to determine why he consulted the naturopath and what, if anything, the naturopath prescribed. Mr. BG also uses acupuncture to manage osteoarthritic pain. It is important to establish whether the acupuncturist uses sterile technique, which is likely in most developed countries but not always the case in other places. 

His use of complementary therapies indicates he actively participates in self-care and is proactive. The GP referred Mr. BG for advice about developing a care plan. It would be essential to include his complementary therapy practitioners in such planning and to ensure his complementary treatments are documented in the conventional medical record. Complementary medicine interactions and contraindications may need to be considered as part of the medicine review. 

Probiotics may help with his gastrointestinal tract symptoms by encouraging beneficial intestinal flora and reducing fermentation of undigested food, which accumulates due to gastric stasis. Likewise, peppermint oil enteric-coated capsules in low doses may help with his gastrointestinal symptoms provided he does not have oesophageal reflux or gall bladder disorders (Kligler and Chaudhary 2007). 

He may have foot pathology as a consequence of the tinea, which needs to be assessed. In addition his ability to care for his feet may be compromised by his osteoarthritis and possibly retinopathy or blurred vision due to hyperglycemia. I would refer him to a podiatrist for foot assessment and education. Charcot’s arthropathy needs to be excluded, or managed if it is present. The extent of the tinea should be assessed. For example he may have tinea in skin folds that also needs to be treated and he could have intestinal Candida given his atopic history.           

I would consider an alternative to Amaryl (glimepiride) given his atopic status. Skin rashes are a known but uncommon side effect of sulphonylureas and Amaryl could be contributing to his skin problems. 

If Mr. BG does have cancer or TB, he and his family will need appropriate counseling and help making difficult life decisions about treatment options, advanced directives, and making a will.

Podiatrist 

The presence of both peripheral neuropathy and tinea pedis puts this man at high risk of foot ulceration. Once the skin integrity is affected by tinea, secondary bacterial infection can rapidly progress to ulceration and cellulitis particularly given his hyperglycemia, which impairs the immune response. Tinea is a common cause of cellulitis in people with diabetes. 

Preventive foot care is essential, although it may not be the priority in this man. Foot hygiene needs to be assessed. He may need education about washing his feet in a pH-neutral product or soap-free skin wash, which is preferable, given his atopic history. He should be advised not to soak his feet, which can cause maceration and increases the risk of infection. 

After cleaning his feet he needs to dry them thoroughly, particularly between the toes where the tinea is likely to be. He should change his socks daily. Topical fungicide lotions and creams such as terbinafine, rather than powders, are recommended and may need to be continued for 1–2 weeks after visible signs of infection subside. 

Preventing reinfection is important. As well as foot hygiene he should alternate his shoes and not wear the same pair every day. He could wash his socks (and possibly underwear) in an antifungal rinse available from the supermarket and dry them in the sun. 

He needs to be educated about the implications of his neuropathy. Intensive foot education, assessing his daily foot care practices and treating any small injuries are essential. A podiatrist can advise about and manage abnormal foot shape such as clawed toes.

Pharmacotherapeutic management 

Key points

  • Medicines should be used in a quality use of medicines framework.
  • Polypharmacy is often necessary to manage the multiple underlying metabolic abnormalities associated with diabetes and its complications and comorbidities.
  • Polypharmacy complicates self-management for the person with diabetes and adds to the cost of managing diabetes.
  • Concordance with medicines is a complex self-care task that has physical, cognitive, and mental components. Medicines knowledge and social factors also play a role.
  • Diet and exercise continue to be essential, even when medicines are needed.
References

Braddon J (2001) Oral hypoglycaemics: a guide to selection. Current Therapeutics Suppl 13: 42–47.

Colquhoun DM (2002) Lipid-lowering agents. Australian Family Physician 31(1): 25–30.

Dunning T (2003) Care of People with Diabetes. Blackwell Publishing, Oxford.

Dunning T, Manias E (2005) Medication knowledge and selfmanagement by people with type 2 diabetes. Australian Journal of Advanced Nursing 11: 172–181.

Durso S (2006) Using clinical guidelines designed for older adults with diabetes mellitus and complex health status. Journal of the American Medical Association 295: 1935–1940.

Faraday N (2006) Chocolate Has Antithrombotic Effects Similar to Aspirin. Proceedings of the American Heart Association Scientific Sessions, Abstract 4101, 14 November.

Goldney R, Phillips P, and Fisher L (2004) Diabetes, depression and quality of life. Diabetes Care 27: 1066–1070.

Greenfield R (2007) Oh, to B12 again . . . metformin use and B12 deficiency. Alternative Medicine Alert 10(4): 46–47.

Hahn K (2007) The ‘Top 10’ Drug Errors and How to Prevent Them. Proceedings of the American Pharmacists Association Annual Meeting, Atlanta, March.

Hirsch I (1997) Sliding scale insulin in hospitalised patients. Summary and comment. International Diabetes Monitor 9(5): 14–15.

Hughes S (2007) The rosiglitazone aftermath: legitimate concerns or hype? Medscape News (www.medscape.com/viewarticle/557198).

Janka H, Plewe G, Busch K (2005) Combination of oral antidiabetic agents with basal insulin versus premixed insulin alone in randomized elderly patients with type 2 diabetes. Proceedings of the American Diabetes Association Scientific Sessions, Abstract 583-P.

Kligler B, Chaudhary S (2007) Peppermint oil may relieve digestive symptoms and headaches. American Family Physician 75: 1027–1030.

Kuritzky L (2006) Addition of basal insulin to oral antidiabetic agents: a goal-directed approach to type 2 diabetes therapy. Medscape General Medicine 6(4): 34–47. Lipid Study Group (1998) The long-term intervention with pravastatin in ischaemic disease. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. New England Journal of Medicine 339: 1349–1357.

Montori VM, Isley WL, Guyatt GH (2007) Waking from the DREAM of preventing diabetes with drugs. British Medical Journal 334: 882–884.

National Heart Foundation (2001) Lipid Management Guidelines. National Heart Foundation, Melbourne.

Nissen SE, Wolski K (2007) Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. New England Journal of Medicine 356(24): 2457–2471.

Palomba S, Orio F Jr, Falbo A et al. (2005) Prospective parallel randomized double-blind

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: Case Discussion #22

For more information on the book, just follow this link to Amazon.com, Managing Clinical Problems in Diabetesalt

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