Creación de proyectos en Educación artística basados en MAE

The patient should be made aware of the symptoms of hyperglycaemia and should make contact if these worsen, especially if weight loss is marked. The technical options to assess the glycaemic response are near-patient (usually self-) testing of blood glucose and laboratory testing (HbA1c levels).

Home blood glucose monitoring is commonly taught to patients in this scenario, but critics argue that it is of little value and is very expensive. Unless a patient or the clinician is going to manipulate therapy based only on the results of HBGM (and this is unlikely to be the case here), one can argue that it should not be routine practice. On the other hand, HBGM will provide immediate feedback to the patient on which aspects of the diet worsen his glucose levels and can be seen to be an essential aspect of patient empowerment. HbA1c levels provide a long-term indication of glycaemic control (typically quoted to be 2–3 months) and, if compared with a baseline value, will give a good indication as to whether conservative measures are being effective. HbA1c also allows for targets to be set, initially aiming for a level below 6.5%, 48 mmol/mol.

Do not forget that a change in blood pressure therapy means that blood pressure monitoring will need to be performed on a monthly basis and, if an ACE inhibitor is used, electrolytes will need to be checked before treatment and after 7–14 days of treatment.

Glucose control for patients with diabetes mellitus 15

CASE 1.5 –  An 84-year-old woman with type 2 diabetes has been treated with gliclazide for 4 years.

A1: What are the treatment options?

The treatment options include:

 further dietary review and manipulation

 add another oral hypoglycaemic agent (sulphonylurea, pioglitazone, gliptin)

 add insulin

 exclude urinary tract infection (UTI) or treat if this is confirmed.

A2: What factors influence the choice of therapy?

The choice of therapy is influenced by the natural history of the patient’s condition, her weight, her current therapy and her age. Type 2 diabetes is a progressive disease and so failure of diet and then oral monotherapy to control her symptoms should be anticipated (and not attributed to failure on the part of the patient). Although a dietary assessment is reasonable (and should be performed as part of the annual diabetes review), she has previously been strict and is not currently overweight. In this setting, it is unlikely that dietary change will make a significant impact. Her current dose of metformin is not at the maximum recommended; however, the dose–response curve tends to be flattened at higher doses (and a further increase is likely to induce side effects), and so additional therapy would be instituted.

UK guidelines suggest a sulphonylurea as second-line, but many clinicians prefer to add a gliptin, as the combination with metformin will not put the patient at risk of hypoglycaemia. Given her age, tight glycaemic control is not a priority and symptomatic relief with low risk of hypoglycaemia is the main aim of therapy. Note that the possibility of diabetic foot complications does not influence the treatment choices.

Although hyperglycaemia causes lethargy and frequency, dysuria with proteinuria and haematuria on dipstick testing suggest the possibility of a UTI (common in hyperglycaemia and a cause of worsened diabetic control). If UTI is confirmed by urine culture, a course of antibiotics would be indicated.

A3: What would be the preferred choice of treatment?

Add a second oral agent to the patient’s current dose of metformin. Options include a gliptin,

pioglitazone and a sulphonylurea. The reduction achieved with any of these therapies is likely to be the same; side effects, especially the risk of hypoglycaemia, are the major reason for opting for a gliptin rather than a sulphonylurea. If the patient remains symptomatic and her HbA1c remains very high, then insulin (in combination with metformin) may have to be considered, but again this would increase the risk of hypoglycaemia.

A4: How would the impact of treatment be assessed?

Given that the patient is already performing HBGM, it is not unreasonable for her to continue this practice. Fasting, pre-meal and pre-bed glucose testing is the norm, with targets below 10 mmol/L without hypoglycaemia being reasonable in this case. HbA1c testing could also be performed for comparison with the pretreatment level. Symptomatic improvement is the main aim of therapy, and the HbA1c target needs to be individualized since the benefits of tight control in this age group are unproven and the side effects of treatment (especially hypoglycaemia) are dangerous.

CASE 1.6 –  A 57-year-old man treated with gliclazide 160 mg twice a day and metformin 500 mg three times a day, who has suboptimal glycaemic control.

A1: What are the treatment options?

The treatment options include:

 further dietary review and manipulation

 increasing the dose of metformin

 adding another oral hypoglycaemic agent (pioglitazone or a gliptin)

 add a GLP-1 injectable therapy

 add insulin.

A2: What factors influence the choice of therapy?

The choice of therapy is influenced by the natural history of the condition, the patient’s current therapy, age and weight, and the presence of retinopathy. The progressive nature of type 2 diabetes is such that almost all patients will end up on insulin if they survive for long enough. Although he is not on maximal doses of metformin, further increases are unlikely to achieve glycaemic targets. Addition of pioglitazone or a gliptin (triple therapy) is an alternative but is often a disappointing combination in this type of scenario. Use of a GLP-1 injectable therapy would now be a popular option in the UK, although current NICE guidelines suggest that this should be offered to patients only where the BMI is over 35 kg/m². Insulin thus becomes a leading option, especially given the patient’s young age and the development of diabetic retinopathy. Clearly the patient is not keen to go on insulin and the reasons for this need to be explored, because many patients are pleasantly surprised at how painless insulin injections are (compared with HBGM) and feel much better when their glycaemic control improves. A dietary assessment is reasonable because weight gain is highly likely with insulin; for this reason, metformin should be continued (while the sulphonylurea may be withheld).

A3: What would be the preferred choice of treatment?

Suggest to the patient that he tries insulin for a period. This will allow him to see how simple the procedure can be and if, like many patients, he feels better on insulin, he may well wish to stay on it.

Twice-daily insulin using fixed mixtures before breakfast and evening meal is a simple regimen that may seem less daunting than basal bolus (where the patient injects fast-acting insulin before each meal and a night-time injection of long-acting insulin). Given the risk of weight gain, the patient should continue on metformin but can cease taking his sulphonylurea.

If a GLP-1 receptor agonist is preferred by the patient (many people hate the idea of insulin, not because of the injections but due to a bad family experience or to fears of hypoglycaemia), then the current options are exenatide or liraglutide. Exenatide can be prescribed as a twice-daily or once-weekly preparation, and liraglutide is given once a day. Both can cause nausea and vomiting. UK guidelines suggest their impact on glycaemic control and weight should be assessed after 6 months, with treatment failure (HbA1c reduction of less than 1% and weight loss of less than 3%) leading to drug withdrawal.

A4: How would the impact of treatment be assessed?

Symptomatic improvement (he may recognize and admit to symptoms in retrospect, especially lethargy) and HBGM will provide feedback on the patient’s progress. He should also monitor his weight. HbA1c will be the ultimate assessment with a lower target (7.0–7.5%, 53–58 mmol/mol) given his young age.

Glucose control for patients with diabetes mellitus 17

OSCE counselling cases

OSCE COUNSELLING CASE 1.3 –  ‘I have been diagnosed as having maturity-onset diabetes. Does this mean that I will never need go on to injections?’

The short answer is ‘no’. Maturity-onset diabetes is the old term for non-insulin-dependent diabetes, now called type 2 diabetes mellitus. The natural history of this condition has been convincingly demonstrated and is one of progressive deterioration in blood glucose control. This is felt to reflect progressive loss of b-cell function over time. Insulin resistance, the other contributing metabolic abnormality, appears to deteriorate before the diagnosis of type 2 diabetes but then remains relatively fixed.

As a result of b-cell failure, dietary change is likely to have a limited and temporary impact, leading to the introduction of oral hypoglycaemic agents and GLP-1 receptor agonists. Ultimately these agents will fail and the patient may need insulin to achieve reasonable glycaemic control. One can argue that if an individual with type 2 diabetes lives for long enough, then insulin is inevitable. This can be used as a justification for early exposure to the use of insulin (handling injection devices, experiencing the injection) so that, when insulin is needed, it is not delayed by unjustified anxieties.

The exception to this rule of progressive glycaemic deterioration may be patients who are obese at diagnosis and manage to lose vast amounts of weight, thereby restoring insulin sensitivity. There are also preliminary data that gliptins and GLP-1 agents can slow the progression of b-cell dysfunction, but these data need to be confirmed.