Ambulatory Care Case Presentation. Kyle Crisco
Preview:
Citation preview
- 1. Kyle Crisco IPPE-III Ambulatory Care Rotation
- 2. Describe the pathophysiology, risk factors, signs/symptoms,
and diagnosis of type II diabetes Recognize common treatment
options for type II diabetes Present an ambulatory care patient
case Discuss primary literature concerning the effectiveness of
U500 insulin Recommend an assessment and plan for the patient
case
- 3. In 2010, 25.8 million people in the U.S. had diabetes
Increasing risk with increasing age Relatively equal for men and
women Most common in non-Hispanic whites 7th leading cause of death
in 2010 Expensive Types Type I diabetes Type II diabetes
Gestational diabetes CDC. National Diabetes Fact Sheet, 2011.
- 4. Family history Overweight or obesity Sedentary lifestyle
Pre-diabetes Gestational DM or baby > 9 lbs Hypertension
Dyslipidemia Jalili M. Chapter 219. Tintinalli's Emergency
Medicine: A Comprehensive Study Guide, 7e.
- 5. Obesity Insulin resistance Excess free fatty acids
Dysregulation of cytokines -cell dysfunction Initial
hyperinsulinemia Postprandial hyperglycemia Excessive hepatic
glucose production Impaired control of gluconeogenesis Funk JL.
Chapter 18. Pathophysiology of Disease, 6e.
- 6. Classic Polyuria Polyphagia Polydipsia Others Abdominal pain
Fatigue Irritability Drowsiness Blurred vision Numbness or
tingling
- 7. A1c 6.5% Fasting plasma glucose 126 mg/dL Two-hour plasma
glucose 200 mg/dL during an oral glucose tolerance test Random
plasma glucose 200 mg/dL Used in patients with classic
signs/symptoms ADA. Executive Summary: Standards of Medical Care in
Diabetes 2014.
- 8. Lifestyle changes Biguanides Glucophage (metformin)
Sulfonylureas DiaBeta, Micronase, Glynase (glyburide) Glucotrol
(glipizide) Amaryl (glimepiride) Thiazolidinediones (TZDs) Avandia
(rosiglitazone) Actos (pioglitazone) DPP-4 inhibitors Januvia
(sitagliptin) Onglyza (saxagliptin) Tradjenta (linagliptin)
- 9. SGLT2 Inhibitors Invokana (canagliflozin) Incretin mimetic
Byetta (exenatide) Victoza (liraglutide) Bydureon (exenatide ER)
Amylinomimetic Symlin (pramlintide acetate) Insulin Rapid-acting
Short-acting Intermediate-acting Long-acting
- 10. Type Onset Peak Duration Rapid-acting 15-30 min 1-2 hours
3-6 hours Short-acting 0.5-1 hour 2-3 hours 4-8 hours Intermediate-
acting 2-4 hours 4-8 hours 8-18 hours Long-acting 2-5 hours
peakless 14- 24 hours U-500 30 min 2-4 hours 10-24 hours Triplitt
CL et al. Chapter 83. Diabetes Mellitus. Pharmacotherapy: A
Pathophysiologic Approach, 8e. Eli Lilly & Co. Humulin R
regular U-500 package insert. 2010.
- 11. Clinical uses Discomfort at the injection site Severe
insulin resistance Cost Genetics
- 12. Subjective
- 13. JS 50 y/o Caucasian female HPI JS presented to the clinic
concerning her type II diabetes. She has a history of an all or
nothing philosophy and has been changing her lifestyle in small
increments. However, during the holidays she admits to eating
everything she wanted. Nighttime snacking is also a big problem for
her, but rationalizes the hand-to-mouth motion is calming for her.
Currently, she gives about 20 units of insulin at each meal, though
she states she does carb count using a carb factor = 3 and
sensitivity factor = 8.
- 14. SH Does not drink or smoke FH Mother breast cancer, HTN,
hyperlipidemia Father alcohol abuse Sister psoriasis Allergies ACEI
(benazepril) angioedema Vaccines Influenza (2012) Tdap (2013)
Pneumococcal (2006)
- 15. Glucose readings have improved and mostly 200) Pre-lunch:
110 349 (most 130 180, also has several >200) Pre-dinner: 70 304
(most 80 160) HS: 88 204 (most 100 120 and 180 200)
- 16. Breakfast Recently began juicing Incorporates vegetables
and small portions of fruits Snacks Chips, popcorn, dry cereal
Switched to wheat bread except at Chick-Fil-A Orders extra crispy
chicken
- 17. PMH Type II diabetes Neuropathy Hypertension Thyroid
disease Depression Anxiety Arthritis Medications Lantus 60 units SQ
BID NovoLOG 25 units SQ TIDAC metformin 1000 units PO BIDAC
gabapentin 300mg PO TID HCTZ 25mg PO daily diltiazem 180mg PO daily
levothyroxine 88mcg PO daily zolpidem 5mg PO QHS prn clonazepam
0.5mg PO QHS prn Tylenol XS 2 tabs PO daily
- 18. Other Dyslipidemia Recurrent UTIs Psoriasis Asthma (mild)
Misc. medications Aspirin 325mg PO daily Vitamin B12 lozenge
- 19. Objective
- 20. Vitals Ht: 54 Wt: 250 lbs 122/80 mmHg 121/61 mmHg
(11/12/13) HR: 87 bpm A1c 10.7% (10/7/13) 9.1% (4/8/13) Lipids
(10/7/13) TC: 166 mg/dL TG: 199 mg/dL LDL : 90 mg/dL HDL: 36 mg/dL
BMI = 42.89
- 21. Na 139 mg/dL K 3.8 mg/dL Cl 98 mg/dL CO2 28 mg/dL Ca 9.5
mg/dL TSH 2.267 mcg/L SCr 0.81 mg/dL BUN 13 mg/dL CrCL 60 mL/min
eGFR 74.84 mL/min/1.73m2
- 22. P. Jones & I. Idris
- 23. Review article 10 retrospective case series P. Jones &
I. Idris. The use of U-500 regular insulin in the management of
patients with obesity and insulin resistance. Diabetes, Obesity and
Metabolism. 2013.
- 24. Recommends initiation of U-500 when total daily dose of
insulin is >200 units Reduce TDD by 10-20% May give in 2-4
injections BID: 60% a.m. and 40% p.m. TID: 40/30/30, 45/35/20,
40/40/20 QID: 30/30/30/10 Lane WS et al. High-dose insulin therapy:
is it time for U-500 insulin?. Endocr Pract. 2009. Lane WS. Use of
U-500 regular insulin by continuous subcutaneous insulin infusion
in patients with type 2 diabetes and severe insulin resistance.
Endocr Pract.2006.
- 25. Mean reduction in A1c of 1% Reduction in number of
injections Weight gain Improved quality of life Reduction in cost
Increase in total insulin dose No significant difference in
combination of oral medications and U-500 compared to those not
taking oral medications P. Jones & I. Idris. The use of U-500
regular insulin in the management of patients with obesity and
insulin resistance. Diabetes, Obesity and Metabolism. 2013.
- 26. Suzanne L. Quinn, M.D., M. Cecilia Lansang, M.D., and
Deanna Mina, Pharm.D.
- 27. To assess the safety and effectiveness of highly
concentrated U-500 regular insulin in patients with
insulin-resistant type 2 diabetes mellitus who were switched from
U-100 insulin. Methods Retrospective cohort study Inclusion 21
patients aged 41-81 y/o with poorly controlled DM and insulin
resistance that were referred to the clinic between 7/1/07- 6/30/08
The duration of diabetes was highly variable, ranging from 222 yrs,
with an average duration of 9.1 5.7 years. Primary outcome
Reduction in A1c Secondary outcomes Reduction in number of daily
insulin injections, daily insulin dose (units/day)and body weight
Suzanne QL et al. Safety and Effectiveness of U-500 Insulin Therapy
in Patients with Insulin-Resistant Type 2 Diabetes Mellitus.
Pharmacotherapy. 2011.
- 28. Response to U-500 Regular Insulin in the 21 Patients
Variable Before U-500 Insulin After U-500 Insulin Change p-value
Hemoglobin A1c (%) 9.5 1.3 7.7 1.6 1.7