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A 72 year old male has had type 2 diabetes for six years. He is on metformin extended release 2.0 grs per day. He does not have any major cardiovascular disease. His last two routine HBA1C levels, taken within a four month period by his GP prior to this appointment, were stable at 9.1%.
How would you conduct the shared-decision making process with this patient?
a. Propose no change to his anti-diabetic treatment
b. Propose adding a DPP4-inhibitor to his metformin treatment
c. Propose adding a sulphonylurea to his metformin treatment
JoeyRio
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This patient who is 72 yrs old with HbA1C 9.1% with short expectancy of life ,the HbA1C may be maintained around 7.5% keeping in mind about the cardiovascular complications in view of any Hypoglycemic event,even though he has no h/o of cardiovascular complications,I think, I may go in for a Sulfonylurea long acting like GlynaseXL(glypizide) 10 mg twice daily to achieve the above target with metformin.
Dr Chid
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FURTHER INFORMATION ABOUT THIS PATIENT:
He is an upper middle class retired professional. His father was non-diabetic and had a sudden death at the age of 93, his mother died of cancer at 76. About 1 and a half years ago he had an appointment with his former GP (now working in another county ). He was on Ramipril 10 mg at night, Simvastatin 20 mg at night and the same 2.0 grs of metformin/day. His BP was normal - verified through ABPM. His BMI was 32, Abdominal circumference 114 cm, LDL-Cholesterol 132 mg/dL, TG: 240 mg/dL. EKG and Echocardiogram were both normal. Carotid ultrasound showed a small increase in its right internal media thickness, with no plaques. He was non-smoker but sedentary; and never took aspirin. His HBA1C had been stable at about 8.4% for the last year. His GP changed his Simvastatin to Rosuvastatin ("Crestor" 20 mg/day and referred him to a multidisciplinary diabetic team.
JoeyRio
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I find treating type 2 diabetes difficult. I really like finding a cure for patients and so much of modern medicine is treating surrogate measurements to reduce risk rather than trying to cure conditions. With more preventative medication elderly people tend to be on multiple medications and so the risk of side effects is higher.
I would probably ask the patient what he wanted. Did he have symptoms that troubled him or did he want to reduce his risks. I would ask him about his attitude to medication and whether he would accept side effects if they produced a significant reduction in risk from disabling illness and if medication was significantly lightly to reduce mortality
I have now retired from full time General Practice and I only do some GP locums in an OOH centre. I still very much enjoy the work, but I do miss some of the continuity of care. When I was a partner, if I had a worry with a diabetic patient had a partner who was very good with dealing with diabetic medications and I would have probably deferred to him. He unlike me was fairly keen on gliptins [DPP4] and would have probably gone for option 2. With a chat about possible side effect of gliptins and a review appointment and a check on his blood tests.
Pat Lush
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This patient is obese with abnormal lipid profile with sedentary habits.He is on Ramipril,Rosuvastatin and Metformin.
I feel,he require life style modifications.He may be advised to go for walking daily for half an hour in the morning or evening.
He requires weight reduction to bring down his BMI below 30.This may be done slowly.This may help him to prevent cardiac problems.
Dr Chid
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The patient is 72 yrs old who had T2DM 6 years ago , what is missing is what is his eGFR ? If he has peripheral neuropathy or diabetic retinopathy? His HBA1C needs to be at or below 7% to decrease macro vascular complications, I wouldn't go for Sulphonylurea firstly because it puts him at risk for hypoglycemia & in his age he may be prone to falls, secondly because he will gain weight & he is already obese BMI 32 , I would go for number 2
I agree with Dr Chid that he needs to change his life style
msm1972
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Definitely diet and lifestyle changes are needed. Right now with an HbA1c of 9.1 % it is very unlikely that the addition of an oral agent would bring it down to goal.
Arrhenius
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I will add sulphonyleura to bring HbA1c to 7.5?
gasha
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Yes i would start this patient on DPP4. He is obese therefore sulphonylurea will not be a good option as it will increase patient weight. Dpp4 will reduce the A1c by 0.8 to 1% reducing the current A1c to roughly 8%. Lifestyle modification like exercise, strict diabetic diet and weight reduction will help him to reduce his A1c for another 0.3-0.5% achieving the target ~ 7.5%
drlyd
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I think here we have limited choice.Either we may go in for Insulin or OHA.Which Insulin or which OHA ,depends on the experience of the clinician and Discussion with patient.
Dr Chid
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FURTHER INFORMATION ABOUT THIS PATIENT:
His eGFR is normal and he has no evidence of neuropathy or retinopathy.
Insulin (for a number of reasons) Is Not in the Horizon of therapeutic options proposed to this man.
The GP of our patient here is now thinking about his clinical evolution after 18 months attending the multidisciplinary diabetic team.
- Great accomplishements he did in 18 months! He lost 4 kg of body weight (and has been keeping it), his BMI came down to 30, his LDL-Cholesterol has been now stable at about the 80ths mg/dL, he has been exercising (regular walking plus going to the gym at least once a week with a personal trainer), and eating a mediterranean diet. Oh yes, lifestyle behaviour is the best medicine (with no side-effects) that I have seen in my life!
- But there is indeed one thing that his GP could not figure out yet.......His HBA1C started to slowly go up from the low 8ths since about 12 months ago.....and now seems to have stabilized at the low 9ths...And his GP has no idea why this is happening, because actually he would be expecting quite the opposite to occur with his HBA1C levels!
- So, what is going on with this man´s glycaemic control? And what should I do now???
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"Why Did This Diabetic Got Better From His Overall Metabolic Syndrome But his HBA1C is Moving Up?" This question is puzzling&perplexing the mind of his GP, because he feels that if he can properly solve this sort of enigmatic issue he would be able to provide to his elderly diabetic the best advices in the shared-decision making process. And what would be the thoughts of my colleagues about this issue... - he said to himself.
JoeyRio