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Time Will Tell What Patient Will Do

Nov 15, 2016
Male, 21 years of age has class III obesity, binge eating disorder, fatty liver, and asthma, and was recently diagnosed with type 2 diabetes. It is his freshman year at a college away from home. He eats in the cafeteria, and has no refrigerator or stove in his room. He visits today after not taking metformin or GLP-1 agonist since at starting school. He is under a lot of stress and states the food at school is terrible, unhealthy, and not diabetes-friendly at all. Note, he has been taught a lower carb meal plan. He says he is not taking Glucophage or Victoza; each of them at low doses gives him terrible diarrhea. He states he checks his glucose twice a week, with fastings in the 90-100 range. He is up 10 pounds since our last visit in September.
I obtained random glucose one hour after eating eggs and sausage. The patient denies having had any carbs for lunch. When I was performing the fingerstick, patient’s response made me wonder if he ever really checks his glucose. Glucose was 302mg/dl. Labs were drawn and urine was obtained.
I informed the patient that his glucose needs to be treated. I would actually have recommended insulin, but I am not sure the patient would actually take it. Although I hardly ever prescribe sulfonylureas, I thought that this may be the only medication he would actually take plus a SGLT-2 inhibitor. He told me he has a history of UTIs, so this somewhat concerned me. I prescribed low dose to start.
We discussed the possibility of hypoglycemia, specifying signs and symptoms to report. I asked the patient what would he do beside take these pills? He said he didn’t think he would do much. Maybe he’d check his blood sugar, but not on a regular basis.
We also discussed bariatric surgery and that at least when he is home for the holiday vacation, he should meet with surgeons to learn more. He states he has thought about this. He is adopted. His birth mother had bariatric surgery and had complications. I informed him times may be different now; it’s at least worth a discussion. He agreed.
Disaster averted? I don’t know. Time will tell.
Lessons Learned:
  • For some, there are so many issues, I have to choose what to start with. In this case, I started targeting the glucose.
  • If it seems patient has needle phobia despite having been taught ways to decrease pain, trust my instinct.
  • Even if sulfonylurea may increase hunger, weight and more, the decision was to target glucose first. If a pill is all the patient will take, then that is the choice. Due to concern about hypoglycemia, if in fact fastings are WNL, starting on a low dose and adding low dose SGLT-2 may help with the weight issue.
  • In people with type 2 and obesity, consider/discuss bariatric surgery as a treatment.

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