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Managing Clinical Problems in Diabetes, Case Study #9: Mrs. MS

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

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Mrs. MS was referred by a diabetes educator in a rural area to a metropolitan diabetes educator. Mrs. MS is 45 and has not had any medical assessment for 18 months. She is married with two children aged 19 and 18 who live at home. She works as a mortgage manager in a local bank. Her periods have become irregular over the past year. She has no idea what her cholesterol level is. She smokes ‘occasionally just socially’. Her father aged 79 has type 2 diabetes and hypertension. Her mother aged 75 has hypertension and dyslipidemia. She has one brother who is overweight and is often tired….

Assessment
  • Overweight BMI 28 (normal < 25 kg/m2 where practical)
  • Waist circumference 32
  • BP 146/84
  • Urinalysis normal
  • Laboratory blood glucose 150mg/dL. (8 mmol/L) random
  • Mixed lipidemia-cholesterol 201mg/dL.(5.2 mmol/L)
  • Trigs 266mg/dL.(3.0 mmol/L)
  • HDL 31mg/dL (0.8 mmol/L)
  • LDL 124mg/dL (3.2 mmol/L)

Twelve months later

Mrs MS presented again having not attended for any follow-up in the meantime. Her mother had an MI 6 months previously.

She reports:
  • Increasing fatigue
  • Breathless at times
  • Hot flushes
  • Irritability
  • Mostly high blood glucose levels

Her HbA1c was 10.7% 6 months ago when she was seen by a locum doctor for the above symptoms. The locum told her to lose weight and get some exercise.

 

Diabetes educator

I would discuss her psychological status and determine whether she is under stress. I would check her insulin technique and take a history of episodes of DKA or hypoglycemia and her home situation. I would review her insulin regimes and diet and make sure she is not having hypos and eating to compensate.

 

Diabetes educator 2

This woman is at significant and immediate risk of a cardiovascular event. She has elevated lipids especially her LDL, a family history of heart disease and dyslipidemia, and her HbA1c is very high, she is overweight, hypertensive, and she smokes. Her increasing fatigue and breathlessness could be due to her hyperglycemia and weight, but an MI needs to be excluded. I would refer her for an ECG, troponins and cardiac enzymes and possibly a cardiac stress test.

She may be menopausal considering her hot flushes, irritability, and irregular periods. Hot flushes are the most commonly reported menopausal symptom and can affect sleep. The frequency and intensity vary greatly and continue for around 5 years but can persist for years, even the rest of the woman’s life. Oestrogen and progesterone levels would be useful and could form the basis of a more detailed sexual history and management strategies. Other causes of fatigue and flushing need to be ruled out such as thyroid disease. Depression also needs to be considered and may be a result of and/or contribute to her inadequate self-care. 

If her oestrogen and progesterone levels are low, a careful discussion about her treatment options are needed. Given her cardiac risk status, hormone replacement therapy (HRT) is probably contraindicated. Some of the newer antidepressants — selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) reduce hot flushes in 60-70% of women (Eden 2006). Oral HRT may reduce total cholesterol (but not triglycerides) and may improve glycemic control, but the long-term cardiovascular benefits are unknown and I would not recommend HRT for Mrs. MS except in the very short term. 

Women are also reluctant to use HRT since the publication of the Women’s Health Initiative (WHI) study (2002) and many use complementary therapies including phytoestrogens such as soya, and herbal medicines such as Dong Quai (Cimicifuga racemosa or black cohosh), which, while there is some good evidence for its efficacy, can cause liver toxicity. Given Mrs. MS’s lipid levels she may have fatty liver, which might exclude its use. Although there is no evidence to support this statement I would not recommend she use it. I would refer her to an endocrinologist or gynecologist for specific advice about her HRT options. She may also require a breast check and pap smear given her history of not attending regular follow-up care.

Smoking is known to exacerbate hot flushes and stopping smoking is a key strategy to alleviate the flushes and reduce her cardiovascular risks. She may benefit from a quit program. 

Mrs. MS is also at risk of osteoporosis and a comprehensive nutritional review is needed. Exercise within her tolerance limits may help with her weight once her cardiovascular status is assessed and her bone strength is clarified. Exercises such as yoga and Tai Chi can improve muscle strength and flexibility. Avoiding hot, spicy foods and drinks and alcohol often helps reduce hot flushes. I would direct her to the Menopause Society (or other relevant) website. (www.menopause.org).

 
Endocrinologist

This woman has metabolic syndrome and needs a fasting glucose to clarify the elevated random glucose. Random glucose under 99mg/dL. (5.5 mmol/L) does not reliably exclude diabetes but above these levels a fasting glucose is required. If the fasting glucose is at or above 99mg/dL. (5.5 mmol/L), a glucose tolerance test is required if significant risk factors for diabetes are present, which is the case with Mrs. MS in view of her family history. However, other causes of this syndrome should be considered and tested for, if clinically indicated, such as Cushing’s syndrome and, rarely, acromegaly. A thyroid function test would also be indicated with the weight gain. If no cause is found, a lifestyle modification program similar to the Diabetes Prevention Program has been shown to reduce the risk of progression to diabetes. At present the evidence is not sufficient to recommend preventive medication.

 

Long-term complications:
 
Key points:
  • Good metabolic control reduces the risk of long-term complications.
  • A prospective regular structured complication assessment program is essential to improving outcomes. It should encompass psychological, spiritual, and social factors, and a comprehensive medication review.
  • An holistic approach to managing complications is necessary.
  • Complications may be ‘silent’.
  • Achieving ‘good control’ is hard work and is very difficult to sustain especially when complications are present.

Prolonged hyperglycemia results in a range of pathological, metabolic and mechanical changes that contribute to the development of diabetes complications. Diabetes complications cause a great deal of morbidity, including psychological stress and can reduce quality of life and life expectancy. Increasing age increases the risk and progression of micro and macrovascular complications and older people diagnosed with diabetes have more morbidity and lower life expectancy than non-diabetics of the same age (Bethel et al. 2007).

Causal mechanisms for long-term complications have been identified and are shown in Table 7.1 (below). The presence of diabetes complications significantly increases the per-patient cost of managing diabetes (Bate and Jerums 2003). A multidisciplinary, multimodal approach is necessary, but achieving stringent blood pressure, blood glucose, and lipid targets is difficult to achieve and sustain.

Three broad levels of susceptibility have been described:

(1) five percent of people with diabetes develop complications even after relatively brief, mild hyperglycemia;

(2) twenty percent tolerate prolonged hyperglycemia; and

(3) seventy-five percent have moderate degrees of susceptibility, and intensive blood glucose, lipid, and blood pressure control may prevent or delay the onset of complications in this group (Raskin and Rosenstock 1992).

The Diabetes Control and Complications Trial (DCCT) (1993) in type 1 diabetes and the United Kingdom Prospective Diabetes Study (UKPDS) (1998) demonstrated that controlling the underlying metabolic abnormalities (HbA1c < 7%) reduced complications and improved long-term outcomes. In the DCCT, microangiopathy was reduced by 39%, neuropathy by 60%, risk of developing retinopathy by 76% and retinopathy progression by 54%. However, only a minority, 37%, actually sustained HbA1c < 7%. The UKPDS demonstrated a reduction in microvascular complications: retinopathy by 25%, erectile dysfunction by 20% and macrovascular disease by 40% by controlling hyperglycemia and significantly, by lowering blood pressure.

The main long-term complications of diabetes are:
  • macrovascular disease such as stroke and cardiac disease;
  • microvascular disease such as nephropathy and retinopathy, which often coexist especially in type 1 diabetes; and
  • neuropathy:
    • peripheral, leading to foot pathology
    • autonomic, which causes gastroparesis, unrecognized hypoglycemia, erectile dysfunction (ED), silent myocardial infarct (MI), and silent urinary tract infection (UTI).
Other less commonly discussed but equally important complications are dental disease, cataracts, musculoskeletal conditions, and psychological distress, all of which impact on self-care and affect the individual’s ability to achieve the recommended management targets and sustain them in the long term.
 
Priorities include:
  • prevention through early identification of people at risk using regular, structured screening programs;
  • early treatment of underlying pathology;
  • improving blood glucose and lipids;
  • managing hypertension;
  • diabetes education;
  • nutritional assessment;
  • regular medication reviews; and
  • psychosocial evaluation.

As function is compromised, rehabilitation programs and assistance with self-care and activities of daily living (ADL) may be needed.

 

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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 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