Disasters Averted

Recently a pump user reported a sudden increase in her glucose levels lasting a couple of days. Her blood sugars were elevated to 275-320mg/dL, with no ketones present.  Changing her infusion sets did not help. Nor did rotating to a new injection site or even using a fresh vial of insulin. After reviewing her insulin pump we noticed a symbol on her “home screen” saying that a special feature was running.

This may not be an actual “physical” disaster averted yet because we don’t know the long-term effects on the people who have taken the ARBs and possibly other medications that were tainted with carcinogens or other “poisons.” When we (health care providers) were first notified of this issue, my first …

Woman, 43 years of age, PCOS, prediabetes, BMI 26, B/P 130/70, A1C 5.5%, Lipids, TC-156, HDL 52, Trig 76, LDL 84, mother of 3 children, visited today. She reports that her mother had PCOS, so was very carefully watching her as a child and adolescent hoping to prevent her from developing the complications of PCOS, such as infertility, obesity, type 2 diabetes, cardiovascular disease, and/or cancer later in life.

Male, 57 years of age, type 2 diabetes. He started with us 6 months ago. When he started seeing us, he was taking  glipizide 10mg twice a day and metformin 1,000 twice daily for his glucose. His A1C was 7.5%, his BMI was 24. We stopped his glipizide and started him on a SGLT-2 and a weekly GLP-1. He met with the dietitian and made some big dietary changes, at least at the start. He also started wearing a CGM and was in our remote monitoring program. He sent me his CGM readings weekly for 4 months. He was doing so well, we decided he need not send me his weekly numbers but rather we’d review during his visits.

A woman, 72 years of age was recently diagnosed with type 2 diabetes. She has a Medicare plan. I don’t know her financial situation but do know she gets Social Security and has other retirement income. Her A1C was rising. We had recommended and taught lifestyle changes which she had difficulty with; she made some changes but not enough to lower her glucose. We added metformin which she did not tolerate, so we discussed one of the SGLT-2s. After hesitating, she agreed to trying one. We gave her samples, she took them. Her A1C lowered to the goal we mutually decided upon.

As noted in our Editor's Letter, David Joffe discusses the importance of how we talk with patients. And to that I'll add...how or if we listen to our patients. David's letter made me think about what we say to patients when they are at risk, when they are diagnosed, and during the treatment phase. If we keep current with our knowledge of diseases — in this case, diabetes — and share what we know today but be clear that we may learn more and differently in the future, the patient may be more open to accept changes and work toward their health goals while at the same time taking into consideration what is known and currently available.

Woman, 55 years of age visited with me 3 weeks ago. Her glucose levels were in the 200-250 mg/dL range. She was actually a new patient of ours; her A1C was 9.2%. We recommended a CGM. She purchased one and brought it to the office for me to teach her how to use it. I did so. This patient is well-educated and seemed tech-savvy. When she left the visit, she "seemed" to understand CGM, what it is, what to do, and how to insert the sensor, get readings, interpret readings, etc.

When I was studying to become a CDE, the students in our class who did not have diabetes were given the assignment to live as though we did have insulin-requiring diabetes for a period of time. It was very helpful. At that time, we did not have continuous glucose monitors (CGM), but we did have insulin, vials and syringes (not sure about the pens but I don’t recall those), glucose monitors, and other supplies. We gave ourselves normal saline as if it were insulin, checked our glucose at least four times/day, carb counted, and everything else required to manage our "diabetes" daily. One incident that stands out to me was a friend faking having a hypoglycemia event while waiting for her food at a restaurant. It was quite an eye-opening period of time for all of us.

If this happens in my practice, I’m sure it likely happens with your patients too. So many of our patients take metformin. They may be new to using metformin or have been taking it for many years. Either way it’s not unusual to have untoward GI side effects from taking it. They may have done fine taking it for years, so they don’t even think about it being their metformin.

Man, 36 years of age, type 2 diabetes, obesity class II, fatty liver, was taking metformin 1,000mg twice daily, and lower dose of SGLT-2. A1C was elevated 9% due to steroids; had been in the 6-7% range. Came in for 3-month follow up — A1C 9.9%, glucose 359, urine positive for glucose and for ketones, gained 19 pounds since last office visit, B/P 126/78-HR 78 and regular. The patient reports he took a "holiday" from everything during the holidays. He ate and drank anything and everything he wanted, including alcohol, and stopped his medications. He complained of  increased hunger and thirst. Very thirsty.