Interactive diabetes case 16: A 61-year-old man with uncontrolled type 2 diabetes on two oral agents
- Lloyd Axelrod, MD
Lloyd Axelrod, MD
- Associate Professor of Medicine
- Harvard Medical School
A 61-year-old restaurant manager with type 2 diabetes returns for a routine office visit. Diabetes was discovered nine years ago on routine examination by his previous clinician when a random blood glucose was 193 mg/dL (10.7 mmol/L). The glycated hemoglobin (A1C) was 8.6 percent. The patient was treated initially with glipizide 5 mg every morning before breakfast.
Over the next two years, the dose of glipizide was increased incrementally to a dose of 10 mg twice daily before breakfast and supper. The blood glucose values improved and the A1C fell to the 7.3 to 7.8 percent range, the level depending for the most part on dietary adherence.
Three years ago the A1C level rose to 8.4 percent and metformin was added. The initial dose of 500 mg twice a day with meals was increased rapidly to 1000 mg twice a day. The A1C fell to the 7.2 to 7.7 percent range.
You saw the patient for the first time one year ago. The A1C was 7.8 percent and you suggested the need for additional medication to reduce the A1C value to <7.0 percent. The patient was reluctant to take another medication and said he would improve his diet. There is a buffet in the restaurant where he worked. Although he was eating three modest meals a day, he was nibbling constantly from about 4 PM until after midnight on crackers, peanuts, sausage, and cheese. He promised to limit himself to a modest snack at the end of each evening. The patient did not return during the intervening year but does so now because his blood glucose values have been rising despite his "improved" diet.
At the present time, the patient reports that he is no longer working in the restaurant and is following his diet. Breakfast is now two slices of whole grain bread and cappuccino. Lunch is a steak and a salad. Supper is often veal parmesan and a salad. He is no longer nibbling in the evening but does have a bedtime snack. He is pleased with his improved diet, notes that it has been a difficult transition, and is unwilling to make further changes.