What’s the Real Story?

Jul 3, 2018
3,279 views

Man, 55 years of age, type 2 diabetes, hypertension, was referred to see us. The patient reports coming to us because he does not think he is getting the right treatment. Reports having been put on insulin upon diagnosis 4 years ago–at which time he had lost 50 pounds, was very hungry, thirsty, and had urinary frequency. When visiting, he did not have his labs from diagnosis but did have labs from 3 months ago at which time A1C was 7, and C-Peptide was 2.2. He said his past endocrinologist changed him to oral meds after his glucose had come down to an average of 140.

During his first visit with us, his glucose was 200mg/dl after eating–was on glipizide 10mg daily, metformin 500mg twice daily and saxigliptin 5mg/day. His blood pressure was 200/102 and pulse 95. He was taking nifedipine 10mg in AM and lisonopril/hydrochlorothiazide 20/25. At this time, our biggest concern was his blood pressure. Since it was taken upon his arrival, not resting, I had planned to retake after sitting and resting, but all of a sudden, he stood up and said he had to leave right away and left. He didn’t leave angry; he had just not planned to stay for the time needed for his visit.

And, oh, by the way–he did mention having taken herbal supplements in the past but he no longer is taking them, so he did not bring to me to show me what they are. He told me his mother likes natural remedies. He also spoke of God a lot during the visit.

I reached out to him and asked him if he had a home blood pressure monitor. Yes he did. I explained how to take it correctly, to please do so and let me know. He did so, it was 160/80-pulse 82. Although elevated, we weren’t as concerned as the day in the office. We were to see him again in a few days.

He came, visited, we got a complete set of labs. His glucose fasting was 200 and blood pressure 180/90-HR 82.
Still mostly concerned about his blood pressure, stopped the lisinopril hydrochlorothiazide and discussed/ordered valsartan 80mg with 25mg hydrochlorothiazide, increased his metformin to 1,000mg twice daily; made appointments with patient for follow up next week with dietitian who teaches lower carb, and with us. I also worked with him and placed CGM so we could get more info on his glucose levels and asked him to keep food log.

I will see the patient tomorrow, but over the past week, he reached out to me to tell me his blood pressure was 220/110. We increased his valsartan. The next day he told me he didn’t take any blood pressure med the day before and his blood pressure was 160/82. I asked him to please resume the valsartan 80mg with the 25mg of hydrochlorothiazide. He said he would and has not gotten back with me. We see him tomorrow.

What I can’t help but wonder is if he has something against taking medication, but will take supplements we don’t know about. I will discuss this more with him during his next visit, as well as prayer. I’ve had many a new patient try to “treat naturally” or “pray away” their diabetes and other chronic diseases, who with time and an accepting way of talking with them have in time agreed to take medications.

Lessons Learned:

Listen, listen, listen to patients. What they may just mention, may be more than they tell you outright.
Be culturally sensitive and accepting. Not that we need to accept the way they are treating or trying to manage their disease process, but accept them as a person: build trust.
Show numbers. Numbers don’t lie. When patients know the numbers they should be working towards–and they see they are not meeting them–they are usually more open to change.
Ask about their fears of taking medications. Understanding their fears can make a richer discussion. Teach that complications of chronic diseases can be more serious than the side effects they may be afraid of, and choose those you think will have less side effects for that person.

Joy Pape, FNP-C, CDE
Medical Editor
Diabetes In Control

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Joy Pape, FNP-C, CDE
Medical Editor
Diabetes In Control

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