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VOLUME 1 ISSUE 5 CASE PD	PD is a 58-year-old woman who was diagnosed with Type 2 diabetes 8 years ago. She is employed as a marketing manager.
CHIEF COMPLAINT »  Unexplained weight loss »  Increasing fasting blood glucose CURRENT MEDICATIONS »  Glimepiride 4 mg/d »  Atorvastatin 20 mg/d PHYSICAL EXAMINATION »  Height: 5'10" »  Weight: 165 lbs »  BMI: 23.7 »  Blood pressure: 118/78 »  Pulse: 84, regular LABORATORY VALUES »  Fasting glucose: 168 mg/dL »  HBA1C: 9.2% »  LDL-C: 106 »  HDL-C: 55 »  Triglycerides: 152 mg/dL NAVIGATION »  Q1: What explains PD’s lack of response to metformin? »  Q2: What is the explanation for the change in PD’s formerly stable condition? »  Q3: What would you do now? Should antibody levels be measured? »  Q4: How would you initiate insulin in this patient? »  Q5: What effect will PD’s weight have on her insulin requirements? »  Q6: What is the primary difference among marketed insulin products? »  Q7: Would you select an intermediate- or long-acting insulin for PD as her basal insulin? »  Q8: What is your starting dose? »  Q9: What is the role of oral agents in nonobese patients with type 2 diabetes? »  Q10: Metformin did not work before in this patient, and her predominant physiologic defect is beta cell dysfunction. Why would you consider metformin, which primarily improves insulin utilization in the liver, now? »  Q11: What is the purpose of adding a TZD, which improves insulin resistance in muscle and adipose tissues, if this patient’s primary defect is insulin secretion, not insulin resistance? »  Q12: At what times should PD be instructed to monitor her blood glucose levels? »  Q13: What can you do to encourage a reluctant patient to accept the fact that insulin therapy is needed? »  Q14: What symptoms of hypoglycemia should you warn about? »  Q15: How should PD be instructed to manage any symptoms of hypoglycemia before calling you?	Q: What would you do now? Should antibody levels be measured? A: Some patients with “adult-onset diabetes” will be shown to have beta cell autoantibodies and slowly developing type 1 diabetes. The correct antibody test to measure is GAD-65, a glutamic acid decarboxylase protein that is a well-characterized beta cell antigen in type 1 diabetes. In the UKPDS study population, the proportion of patients with positive antibody tests decreased with increasing age at diagnosis, but those with positive tests had lower BMI levels (mean 24.9 vs 31.7) and higher HbA1c (9.7 vs 8.7%). Almost all (94%) of patients with positive antibody tests required insulin therapy by 6 years, compared with 14% of those without the antibodies.4 You might perform the test to provide some prognostic information in this catabolic patient. Even though she needs insulin therapy at this point, if the test is positive, you can be certain that she will have a progressive requirement for a more intensive insulin regimen over the next few years. The results from PD’s antibody testing were negative. This patient may have a functional, genetically programmed form of beta cell dysfunction.
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