University  |   Hospital  |   Pulse  |   JeffNet   |   RAP

Find People  |   JeffMail  |   JeffCal  |   JeffShare

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: How would you initiate insulin in this patient? A: Basal insulin should be instituted first in this patient. If basal insulin is insufficient to control PD’s hyperglycemia, bolus insulin can be added at mealtime. Some patients with type 2 diabetes may be controlled with basal insulin in combination with oral therapy, but patients who are severely insulin resistant may require large amounts of insulin and multiple daily injections.
	Questions? Contact 1-888-JEFF-CME (533-3263) or http://jeffline.jefferson.edu/jeffcme
The Thomas Jefferson University web site, its contents and programs, is provided for informational and educational purposes only and is not intended as medical advice nor is it intended to create any physician-patient relationship. Please remember that this information should not substitute for a visit or a consultation with a health care provider. The views or opinions expressed in the resources provided do not necessarily reflect those of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson Health System or staff. Return to Thomas Jefferson University Home Page