Disasters Averted

Female, 57 years of age, type 2 diabetes, metformin 1,000mg twice daily for 12 years, came in with weakness, anemia, tingling of fingers and toes. Her A1C had always been below 7%. Some in my office thought she had developed diabetic peripheral neuropathy. I could not disagree, but I also knew metformin can cause vitamin B12 deficiency.

Male, 66 years of age, type 2 diabetes, class III obesity, peripheral neuropathy, multiple toe amputations, hypertension, hyperlipidemia and, most importantly, a 2-year-old granddaughter. Patient taking 100 units long-acting insulin, sulfonylurea, metformin, beta blocker, and statin. Checks glucose once in a while; in the 200 to 270 range when checks. A1C 9.3%.

Woman, 42 years of age, class III obesity, type 2 diabetes diagnosed in the past year, binge eating disorder. Very motivated to change lifestyle when first diagnosed. She goes off and on her medication. When off, she binges. As an hcp, I wondered about the severe changes from totally "on" to totally "off." Yes, this patient is receiving counseling, CBT.

One day a 31-year-old woman who had recently been hospitalized and subsequently diagnosed with type 1 diabetes came into our diabetes clinic for education. She had been discharged from the hospital less than a week prior to coming to our clinic. She was frustrated when she arrived, as her blood sugars had become increasingly elevated after leaving the hospital. She had called her primary care physician and he instructed her to increase her dose of long-acting insulin. Still, her blood sugars had not improved.

56-year-old man, type 2 diabetes, had been prescribed SGLT-2 to lower his glucose levels. He had been taking an SGLT-2 for the past two years. His A1C, blood pressure and weight were elevated since the last visit 3 months ago. When asked if he was doing anything different, he said he had read articles and seen on TV about these types of medications causing heart disease, so he stopped taking his.

Female, type 1 diabetes, 32 years of age, glucose fluctuations, has worn a pump for years. Thought she “had” to. Has never liked wearing a pump. Met her for the first time, informed her she does not have to wear a pump. Some people are able to manage their diabetes as well or even better with injections. She wanted to try.

A patient with diabetes gets her meds, prescribed by a nurse practitioner, from a national chain pharmacy in New York. She was planning travel to Hawaii. Patient did not refill her meds at home in New York before leaving for her travel in Hawaii because it was too early. Insurance would not pay until closer to the refill date. She thought she could wait until the time insurance would cover, go to a location where she was traveling and pick it up there. She’d done that during her travels in the past. It did not work in Hawaii.

Woman, 55 years of age, type 2 diabetes for 15 years. When first diagnosed, did all she could to learn everything about managing her diabetes. She even went to two complete diabetes education courses. The second she paid for on her own. In time, she started checking less, ate more and more unfriendly diabetes foods, and due to a chronic ankle problem, became more and more inactive. After losing her insurance, she then stopped taking her medications and checking her glucose, until she noticed bloody drainage on her clothes from rashes several places on her body.

Woman, 67 years of age, newly diagnosed with type 2 diabetes with an A1C of 7.8%. Met with PCP who prescribed metformin ER and referred patient for diabetes education. Patient made some dietary and physical activity changes at first, but upon return visit her A1C was 8.5%. She reported she did not take the metformin. “I can’t swallow big pills. The bottle said not to crush or break the tablets. They were just too big to swallow. So then I just gave up on everything.”

Woman, 58 years of age, history of PCOS, prediabetes, strong family history of type 2 diabetes, cardiovascular disease and obesity. This patient lives a healthy lifestyle, including a lower carb meal plan, is very active, and keeps her weight down. Those interventions did not lower her A1C, so she educated herself and asked her NP/CDE if she should start metformin. This was about 20 years ago. Since starting metformin, A1C is in the 5.1-5.5% range. Patient regularly checks glucose, which was recently rising. A1C rose to prediabetes range again. Started on GLP-1 by NP/CDE. Patient then went to a new PCP who told her she should not be taking metformin or the GLP-1 because she does not have diabetes. Wanted to refer her to an endocrinologist....