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Question #822

Mr. Hernandez is an overweight (BMI 30 kg/m2), 45-year-old plumber of Hispanic heritage who arrives at your office for a first-time visit. He has not been to a physician during the last 7 years because he hasn’t always had health insurance and “doesn’t like going to the doctor.” However, he has been noticing lately that his vision seems a little blurry and he’s developed a red, itchy rash in his groin. He is a non-smoker and recalls being told a long time ago that he should eat a low salt diet, but he can’t remember why. On examination, his BP is 154/96 mm/Hg, and his pulse is 72, RR 22. His physical exam is notable for signs of a yeast infection in his groin. You order a CBC, Chem 12 panel and A1C to be drawn that day before he leaves. You advise him how to treat his skin infection. When you receive the results of the Chem 12 panel, it shows a random plasma glucose of 162 mg/dL and A1C 7.3%. You call Mr. Hernandez and ask him to return the next morning, before he has eaten, for additional labs. You order the necessary labs.

Mr. Hernandez labs return and are notable for A1C 7.5, FPG 137 mg/dL, LDL-cholesterol 190 mg/dL, HDL-cholesterol 38 mg/dL and triglycerides 232 mg/dL. You discuss his lab results, his diagnosis and how to manage diabetes and make referrals to the appropriate diabetes team clinicians. You start Mr. Hernandez on metformin, lifestyle modifications, an ACE inhibitor, and a statin. You are looking to achieve A1C <7%, BP<140/90 mmHg, LDL

You ask Mr. Hernandez to return in 3-months time to evaluate how everything is going. However, he fails to keep his appointment. He returns 1 year after his initial diagnosis for a recurrent yeast infection. His A1C is currently 8%. Upon questioning, he admits that while he has been good about taking his “heart meds,” he has not taken the “sugar pill” because he didn’t like it.

What side effect did the patient most likely find intolerable?

Correct

Answer:  A. Diarrhea and abdominal cramping

Metformin may be contraindicated in some patients and other patients may not tolerate its side effects well. Gastrointestinal side effects are common. If metformin is not tolerated or is contraindicated, the ADA/AED guidelines recommend initiating therapy with a drug from another class and proceeding accordingly.

Reference(s):

nzucchi S, et al. Management of hyperglycemia in type 2 diabetes, 2015: A patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012; 35(6):1364-1379

Inzucchi S, et al. Management of hyperglycemia in type 2 diabetes: A patient-centered approach. Update to a Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2015; 38:140-149.

Incorrect