Interactive diabetes case 13: Deterioration of metabolic control in a 59-year-old man with type 2 diabetes complicated by retinopathy, nephropathy, and neuropathy
- Lloyd Axelrod, MD
Lloyd Axelrod, MD
- Associate Professor of Medicine
- Harvard Medical School
A 59-year-old man is referred to you because of uncontrolled diabetes. Fourteen years ago the patient was found to have a blood glucose level of about 300 mg/dL (16.7 mmol/L) on a routine examination. He was treated with a program of diet, exercise, and glipizide. The glucose level fell to the 110 to 140 mg/dL (6.1 to 7.8 mmol/L) range.
The patient relates that for the next eight years, “I avoided it all,” following no regimen and taking no medication for diabetes. Three years ago his glycated hemoglobin (A1C) was 13 percent. He developed proliferative diabetic retinopathy and had a total of 11 laser treatments to both eyes and a right vitrectomy. He also developed progressive nephropathy.
When his vision deteriorated, he saw a clinician and resumed care of his diabetes. He followed a diet, began to exercise, and started to take NPH insulin, currently 52 units every day at bedtime. The A1C fell to 7.4 percent over the next nine months.
In the last year, the glucose values, previously predictable, became erratic, with nearly normal glucose control on some days, inexplicable hyperglycemia on others, and occasional hypoglycemia before lunch. His most recent laboratory studies include a blood urea nitrogen (BUN) of 44 mg/dL, a serum creatinine of 2.7 mg/dL, a potassium level of 5.3 mEq/L, an A1C of 9.7 percent, and 2 + proteinuria. He has aching pain in his legs, mostly at night, from his feet to the level of the mid-calf. Light touch sensation is diminished to the thighs. Vibratory sensation is absent at the great toes and reduced at the medial malleoli and tibial tubercles. Deep tendon reflexes are absent at the ankles and the knees.
He has had nausea, abdominal pain, and intermittent constipation in the last year.